Chest Infections |

Strongyloides Hyperinfection: A New Paradigm FREE TO VIEW

Sandra Galarza-Vargas, MD
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VA Caribbean Healthcare System, San Juan

Chest. 2013;144(4_MeetingAbstracts):237A. doi:10.1378/chest.1704740
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SESSION TITLE: Infectious Disease Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Strongyloides stercoralis affects 30 to 100 million people worldwide, being a common cause of abdominal pain and diarrhea. Strongyloides infection can be clinically categorized into: acute, chronic uncomplicated and chronic complicated. Chronic complicated strongyloidiasis also called hyperinfection syndrome. Glucocorticoid treatment and HTLV -1 infection are the two conditions associated with triggering hyperinfection; Cases have been reported with hematologic malignancy, malnutrition, and AIDS.

CASE PRESENTATION: A 63 year old man presented to this center in May 2012 due to ileal obstruction. Proximal jejunum biopsy confirmed the presence of Strongyloides stercoralis. Upon successful treatment with oral ivermectin, the patient was discharged home. Subsequently, the diagnosis of Good’s syndrome was established in August 2012 with mediastinal mass biopsy diagnostic of thymoma, as well as the presence of hypogammaglobulinemia. After four courses of chemotherapy, and last one a week before admission, comes January 2013 due to vomiting, abdominal and chest pain. The patient was afebrile, normotensive and tachycardic. Lungs were clear to auscultation and abdomen was unremarkable. Abdomino-Pelvic CT Scan was suggestive of jejunitis and focal dilatation of proximal jejunum. On the seventh day of admission, he developed gram negative bacteremia and bilateral alveolar reticular infiltrates on chest film leading to respiratory failure and subsequent intubation and mechanically ventilated. His abdomen became tympanic, with diminished peristalsis as well as presenting urticarial rash at periumbilical area. Fiberoptic bronchoscopy was performed showing progressively more hemorrhagic aliquots, consistent with diffuse alveolar hemorrhage. Pulmonary cytopathology reported parasitic organisms consistent with Strongyloides stercoralis. Patient was treated with oral, rectal and subcutaneous ivermectin in combination with oral albendazole and gammaglobulin supplementation. Marked resolution of symptoms and evidence of erradication of parasite in sputum and stool cultures were seen after 8 weeks of therapy.

DISCUSSION: Good’s syndrome is a rare cause of combined B and T cell immunodeficiency in adults. The unique immunosuppresory clinical features of this patient with hypogammaglobulinemia and chemotherapy, poses challenges that the physician needs to be aware.

CONCLUSIONS: Early diagnosis and high index of suspicion before commencing immunosuppressive therapy is very important. Mortality rates of 20% - 40% may be expected despite optimum treatment.

Reference #1: Strongyloides Hyperinfestation With Pulmonary Hemorrhage and ARDS Padmini Nagaraj, MD School of Medicine, Dayton, Ohio

Reference #2: Strongyloides duodenitis: case report and review of literature. Kakati B, Dang S J Natl Med Assoc. 2011 Jan;103(1):60-3. Review.

Reference #3: What is Good’s syndrome? Immunological abnormalities in patients with thymoma P Kelleher1, S A Misbah2 J Clin Pathol 2003;56:12-16 doi:10.1136/jcp.56.1.12

DISCLOSURE: The following authors have nothing to disclose: Sandra Galarza-Vargas

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