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Description
A woman aged 36 years with untreated AIDS presented with symptoms of abdominal pain, increasing dyspnoea with haemoptysis and weight loss. Prior to arrival in the USA, she lived in the Democratic Republic of Congo. She was afebrile, and had bilateral expiratory wheezing on examination. T-helper CD4 cell count was 106 (9%) and HIV PCR quantification was 1 146 362 copies/mL. A CT scan revealed bilateral ground glass opacities, diffuse small bowel wall thickening and mild hepatosplenomegaly. A bronchoscopy with bronchoalveolar lavage (BAL) showed 11 nucleated cells/μL noted (11% neutrophils, 4% lymphocytes, 77% mononuclear cells and 8% eosinophils). BAL microscopy noted live Strongyloides larvae (video 1 and figure 1). Cytopathology studies were also notable for the presence of Strongyloides stercoralis larvae (figure 2). Blood cultures grew Klebsiella pneumoniae. This clinical amalgamation of enteritis, Gram-negative rod bacteraemia and pulmonary invasion of filariform larvae is classic for Strongyloidiasis hyperinfection syndrome. She was treated with 7 days of ivermectin prior to initiation of antiretroviral therapy, and reported resolution of symptoms on follow-up.
Bronchoalveolar lavage microscopy showing a Strongyloides stercoralis larva.
Lung cytopathology with Prussian Blue staining, at ×200 magnification, confirming the presence of Strongyloides stercoralis.
Bronchoalveolar lavage microscopy demonstrating a live and mobile Strongyloides stercoralis larva.
This case highlights the importance of having a low index of suspicion for Strongyloidiasis, especially in the immunocompromised host. Steroid use, in particular, has been associated with dissemination of disease and worse outcomes.1 Often, the presenting diagnosis is septicaemia with enteric organisms, thought to be from translocation of bacteria by the larvae.2 The organisms can be detected in stool, and have been found to persist in humans for several decades since travel to an endemic area.3
Learning points
Consider Strongyloidiasis in the differential when dealing with recurrent septicaemia with enteric organisms.
Strongyloidiasis has been known to persist and cause recurrence of disease after initial successful treatment.
Steroid use can be associated with dissemination and severe disease.
Acknowledgments
The authors thank Stephen Raffanti, MD, William Stone, MD, and Todd Hulgan, MD.
Footnotes
Contributors KC and KK contributed equally in direct patient care, as well as in the compilation of this summary, literature search, and formatting of media. CW was this patient's primary care physician who initiated expedited workup of her persistent symptoms. CW was actively involved in the investigations ordered while inpatient. AP was the attending physician on the team, supervising patient care.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.