STRINGS OF FURY: A CASE OF STRONGYLOIDES HYPERINFECTION SYNDROME IN A CHEMOTHERAPY-NAIVE PATIENT WITH EXTENSIVE SCLC

Abstract

SESSION TITLE: Chest Infections 2 SESSION TYPE: Med Student/Res Case Report PRESENTED ON: 10/09/2018 05:00 PM - 06:00 PM INTRODUCTION: Strongyloidiasis is one of the most neglected tropical diseases. Diagnosis is difficult because of non-specific clinical features, irregular larval output and lack of specific test. This infection can be chronic and asymptomatic but a change in immune status can lead to increased parasite burden, hyperinfection syndrome, dissemination, and death if unrecognized. CASE PRESENTATION: An 80-year old Filipino male diagnosed with Small Cell Lung Cancer - extensive disease (brain and liver metastases) was admitted due to a 5-day history of watery blood-streaked stools, dry cough and decreased sensorium. Dexamethasone was started for raised intracranial pressure. The patient was started on empiric antibiotics for pneumonia (Fig2) and acute gastroenteritis. Fecalysis showed Strongyloides larvae (Fig1) and Albendazole was started. Neurologic and respiratory status worsened and necessitated ventilatory support. Endotracheal aspirate smear revealed Strongyloides rhabditiform larvae (FIg3). Blood culture revealed Klebsiella pneumoniae. Despite adequate antibiotic coverage and discontinuation of steroids, the patient continued to deteriorate and was brought home. DISCUSSION: Hyperinfection is a syndrome of accelerated autoinfection which may or may not result from alteration in immune status. Development of gastrointestinal and pulmonary symptoms is seen. The hallmark is detection of increased numbers of larvae in stool and/or sputum. Regardless of dose or route of administration, even short courses (6-17 days) of steroids in immunocompetent patients have been associated with hyperinfection syndrome and death.Hyperinfections are often complicated and, rarely, preceded by infections caused by gut flora that gain access to extraintestinal sites, presumably through ulcers induced by the filariform larvae or by virtue of being carried on the surface or in the intestinal tract of the larvae themselves. Blood cultures from patients with hyperinfection have grown Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas, Enterococcus faecalis, coagulase-negative staphylococci, Streptococcus bovis, and Streptococcus pneumoniae.Centers for Disease Control and Prevention recommend that immunosuppressive therapy should be stopped or reduced if possible. Only Ivermectin is recommended for hyperinfection however it is not available in the Philippines. Albendazole is recommended as alternative regimen for acute and chronic forms strongyloidiasis. CONCLUSIONS: As the number of immunosuppressed individuals increase, a more thorough investigation is warranted to detect situations under which S. stercoralis infection can potentially worsen. Early diagnosis is a challenge as it may mimic other diseases. Primary prevention as well as better approaches to identifying, screening, and treating those at risk will likely decrease the morbidity and mortality associated with this hyperinfection syndrome. Reference #1: Olsen A, van Lieshout L, Marti H, et al. Strongyloidiasis - the most neglected of the neglected tropical diseases? Trans R Soc Trop Med Hyg. 2009; 103:967-972. Reference #2: Mejia R, Nutman TB, Screening, prevention, and treatment for hyperinfection syndrome and disseminated infections caused by Strongyloides stercoralis. Opin Infect Dis. 2012 August ; 25(4): 458-463. Reference #3: Keiser PB, Nutman TB. Strongyloides Stercoralis In The Immunocompromised Population. Clinical Microbiology Reviews, Jan. 2004, P. 208-217 DISCLOSURES: no disclosure on file for Raquel Victoria Ecarma; No relevant relationships by Myrna Mendoza, source=Web Response No relevant relationships by Irene Rosellen Tan, source=Web Response