Strongyloides hyperinfection syndrome (SHS) is one of several clinical manifestations of Strongyloidiasis and has a mortality rate exceeding 80%.Herein, we describe a case of SHS with a novel feature.CASE DESCRIPTION: A 69 year-old male from Venezuela with a history of COPD presented to our institution for an evaluation of progressive dyspnea not explained by his underlying lung disease. Three weeks prior to admission, he developed episodic fevers, rigors, loose stools, and progressive hypoxemia with worsening pulmonary infiltrates refractory to treatment with steroids and antibiotics. Within twelve hours of arrival at our institution, the patient’s condition acutely deteriorated requiring transfer to the ICU. He underwent bronchoscopy with bronchoalveolar lavage (BAL), and was empirically treated for suspected Pneumocystis Carnii Pneumonia (PCP) with intravenous trimethoprim/sulfamethoxazole, and for a presumed superimposed nosocomial pneumonia with ciprofloxacin and ticarcillin-clavulanate. The BAL specimens subsequently revealed the presence of multiple pathogens including Strongyloides stercoralis, Pneumocystis carnii, Pseudomonas aeruginosa, Cytomegalovirus, herpes simplex virus, and Aspergillus species. Blood cultures revealed Enterococcus sp., Salmonella sp., and the serum was positive for the CMV pp65 antigen. Ivermectin, voriconazole, and gancyclovir were then added to his medical regimen, and a steroid taper was instituted.DISCUSSION: SHS is a syndrome characterized by high organism burden due to autoinfection that most commonly occurs in immunocomprised hosts. The recovery of multiple pathogens is due to a “piggy back” phenomenon that is believed to occur when enteric pathogens are transferred to the bloodstream attached to Stongyloides larva. To our knowledge, this is the first reported case of SHS and PCP occurring simultaneously.
Due to its extremely high mortality rate, Strongyloides hyperinfection syndrome must be considered early in the differential diagnosis of respiratory failure when multiple pathogens are recovered in a patient from an endemic area.
P. Abraham, None.