SESSION TITLE: Infectious Disease Cases II
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Sunday, October 27, 2013 at 01:15 PM - 02:45 PM
INTRODUCTION: Diffuse alveolar hemorrhage is an uncommon but often catastrophic and fatal manifestation of disseminated strongyloidiasis.
CASE PRESENTATION: A 50 year-old Chinese woman with SLE on chronic steroid therapy had been hospitalized for altered mental status with electrolyte abnormalities. Five days post admission she developed acute hypoxemic respiratory failure requiring intubation, and a fall in hemoglobin by 3g/dl was noted. Chest x-ray showed interval development of diffuse bilateral airspace infiltrates, confirmed on chest CT chest. Bronchoalveolar lavage revealed persistent bloody return consistent with alveolar hemorrhage. Pulse steroid therapy was started but then discontinued when two days later BAL cytology revealed filariform larvae of Strongyloides stercoralis. A two day course of Ivermectin was administered and extended for another 5 days after S. stercoralis larvae were identified in the stool. The patient however developed multi-organ failure and died.
DISCUSSION: Diffuse alveolar hemorrhage is a rare complication of disseminated S. stercoralis. It is characterized by respiratory compromise, diffuse alveolar infiltrates and progressively bloody BAL. Alveolar hemorrhage results from disruption of alveolar-capillary basement membrane and capillary wall damage by invading filariform larvae. It is also postulated that release of cytotoxic chemokines by larvae results in endothelial inflammation. Disseminated strongyloidiasis results from the rapid reproduction and transformation of noninfectious rhabditiform larvae into infectious filariform larvae within the gut; which then transmigrate into the systemic circulation. This results in massive dissemination of filariform larvae to multiple organs such as lungs, heart, skin, liver and central nervous system. Patients with deficient host cellular immunity are at greatest risk. These include hematopoietic stem cell or solid organ transplant recipients, patients with HIV or HTLV-1 infection, chronic kidney disease, malnutrition, diabetes mellitus, chronic alcoholism, use of calcineurin inhibitors and those on chronic corticosteroid therapy. Antihelminthic therapy with Ivermectin or thiabendazole is imperative but optimal duration of therapy is unknown. High dose steroids can exacerbate the situation and so the tapering or avoidance of immunosuppressive therapy should be considered. The mortality rate, reported as 70-86%, remains high despite therapy.
CONCLUSIONS: Disseminated strongyloidiasis should be considered as a differential for pulmonary complications in the immucompromised patient,especially if from an endemic area.
Reference #1: Woodring JH et al. Pulmonary Strongyloidiasis: clinical and imaging features Am J Roentgenol 1994; 162:537-542.
Reference #2: Lam CS et al. Disseminated strongyloidiasis: a retrospective study of clinical course and outcome. Eur J Clin Micro Infect Dis 2006; 25:14-18
DISCLOSURE: The following authors have nothing to disclose: Dionne Morgan, George Apergis
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