INTRODUCTION:Strongyloidiasis results from infection with Strongyloides stercoralis. Manifestations of infection can range from asymptomatic eosinophilia in the immunocompetent host to disseminated disease with sepsis when immunocompromise is present. We report a case of Strongyloidiasis following immunosuppression for a C-ANCA associated vasculitis.
CASE PRESENTATION:A 65-year-old white female with a complex medical history was admitted for evaluation of nausea, vomiting, abdominal pain, lethargy, and dyspnea. Three months prior to admission, she presented with a headache and an elevated ESR. A temporal artery biopsy was performed and consistent with temporal arteritis. Prednisone 60mg daily was initiated. Two months prior to admission and while on high-dose prednisone, she developed massive hemoptysis with acute respiratory failure. Bronchoalveolar lavage suggested diffuse alveolar hemorrhage, but surgical lung biopsy showed only recent hemorrhage and no evidence of vasculitis. Serologic testing, however, revealed a positive C-ANCA at a 1:320 titer and positive PR3. Renal biopsy was considered but ultimately not pursued, as serum creatinine was normal and no active urine sediment was observed. A diagnosis of C-ANCA associated pauci-immune systemic vasculitis was made, and cyclophosphamide was initiated with prednisone. Her ICU and hospital course were prolonged, but she gradually improved and was discharged to a skilled nursing facility. After five days at this facility, however, she developed the abdominal and respiratory symptoms outlined above and returned for further evaluation.Within 12 hours of this admission, she developed rapidly progressive hypoxemic respiratory failure requiring mechanical ventilation, fever, and hypotension. Eosinophilia of 12% was noted, and her chest radiograph showed diffuse opacities bilaterally. She received broad-spectrum antibiotics, and diagnostic bronchoscopy was performed. Both BAL and transbronchial biopsies demonstrated Strongyloides stercoralis and were characteristic of the infectious stage of the organism’s life cycle. She received anti-parasitic therapy with Albendazole, but did not clinically improve. Multi-organ dysfunction ensued, and a decision to withdraw care was ultimately made by her family.
DISCUSSIONS:Strongyloides is endemic in tropical and subtropical regions but may also occur in more temperate climates. The highest rates of infection in the United States are in Appalachia and the Southeast, in immigrants from endemic areas, and in those with occupational exposures in endemic areas. In contrast to other helminthic parasites, S. stercoralis can complete its life cycle entirely within a human host, thereby allowing for a significant rise in the worm burden through the process of autoinfection. While autoinfection is usually contained by an intact immune response, organisms may still persist for decades and cause clinical manifestations long after the initial infection. Most infected patients do not experience prominent symptoms. Common manifestations include waxing and waning cutaneous, gastrointestinal, or pulmonary symptoms. Eosinophilia in the absence of symptoms may also occur. In patients with depressed cell-mediated immunity (CMI), autoinfection may lead to potentially fatal hyperinfection with disseminated disease. This hyperinfection syndrome, resulting from massive systemic dissemination of filariform larvae, may be characterized by fever, nausea, vomiting, abdominal pain, dyspnea, cough, and hemoptysis. In severe cases, shock and organ dysfunction can occur. The likelihood of developing the hyperinfection syndrome is increased if CMI is impaired by underlying malignancy, malnutrition, alcoholism, transplantation, or administration of corticosteroids or cytotoxic drugs. Therefore, it is important to detect and eradicate Strongyloides prior to the initiation of immunosuppressive therapy.
CONCLUSION:Although uncommon, Strongyloidiasis should be considered in patients with unexplained eosinophilia, serpiginous skin lesions, or pulmonary or gastrointestinal symptoms, and excluded prior to initiating immunosuppressive therapy.
DISCLOSURE:Chad Case, No Financial Disclosure Information; No Product/Research Disclosure Information