Hyperinfection Syndrome: Strongyloidiasis in an Immunocompromised Patient

Abstract

SESSION TITLE: Pulmonary Manifestations of Systemic Disease 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Strongyloides stercoralis is a human intestinal nematode that is endemic in rural, tropical, and subtropical regions. Immunocompetent individuals may become infected but usually remain asymptomatic. Immunocompromised individuals are more susceptible to systemic disease such as patients with HTLV-1, recent transplant, or chronic steroid use. The clinical manifestations of strongyloidiasis in immunocompetent individuals are usually mild to moderate symptoms. Immunocompromised individuals are more prone to the hyperinfection syndrome, which is the accelerated cycle of autoinfection leading to subsequent large-volume larval dissemination to the lungs, liver, heart, and central nervous system. CASE PRESENTATION: We report a case of a 74-year-old woman with a history of scleroderma, chronic dysphagia, chronic respiratory failure secondary to scleroderma-related interstitial lung disease (ILD) on oral prednisone, who presented with fatigue of a few days’ duration. The patient had a recent hospital admission for extended-spectrum beta-lactamase (ESBL) Klebsiella bacteremia. During this subsequent hospitalization, she had multiple episodes of respiratory distress which were thought to be chronic aspiration given her history of dysphagia, and chest x-rays showed only chronic reticular changes attributed to ILD. However, on day 4, the patient’s clinical condition deteriorated, and she developed hypoxic respiratory failure requiring intubation and transferred to the ICU. A repeat CXR revealed a new left upper lobe (LUL) infiltrate and she was started on broad-spectrum antibiotics for possible aspiration pneumonia. During the following twenty-four hours, subsequent CXRs showed rapid worsening of the LUL dense opacity. Her blood cultures returned positive for ESBL Klebsiella, and a bronchoscopy was performed with bronchoalveolar lavage of the LUL. The microbiology laboratory noted that there was an organism “crawling” on the plate which was subsequently identified as Strongyloides. The patient was started on ivermectin but developed worsening septic shock and subsequently passed after cardiac arrest. DISCUSSION: It is important to consider screening for Strongyloides in immunocompromised individuals, especially those on long-term steroids and in patients with unexplained Gram-negative bacteremia. Strongyloides can lay dormant for decades; our patient was originally from Puerto Rico but had not been there since she was 16 years old. Clinical awareness of the possibility of chronic latent infection should prompt clinicians to consider screening for Strongyloidiasis which could ultimately prevent hyperinfection syndrome and its associated high mortality. CONCLUSIONS: It is important to consider screening for Strongyloides in an immunocomprised individual. Reference #1: Paul B. Keiser Keiser, P.B., Nutman, T.B. Strongyloides stercoralis in the Immunocompromised Population. Clin. Microbiol. Rev. January 2004 ; 17(1): 208-217. DISCLOSURE: The following authors have nothing to disclose: Lien-Khuong Tran, Glenda Agustin, Anthony Saleh No Product/Research Disclosure Information