Strongyloidiasis and Diffuse Alveolar Hemorrhage in a Patient with Systemic Lupus Erythematosus

Fernando Gonzalez-Ibarra,Basheer Tashtoush,Lindsey Schachter,Amer K Syed,Parag Chevli,Jioty Matta,Sahar Eivaz-Mohammadi,Valentin Marian,Maninder Kaur

doi:10.1155/2014/278390

Abstract

The presence of Strongyloides stercoralis infection in patients with systemic lupus erythematosus (SLE) has been described previously. Strongyloides stercoralis hyperinfection syndrome (SHS) that usually develops in patients under immunosuppressive therapy may affect a variety of organs, but the presentation with diffuse alveolar hemorrhage (DAH) is rare with only a few cases described in the literature. We present the case of a 36-year-old Hispanic female with a past medical history relevant for SLE and a recent diagnosis of lupus nephritis and hypertension. The patient who developed sudden and progressive abdominal pain and respiratory distress, with the presence of bilateral crackles and severe hypoxemia, is currently under treatment with steroids and cyclophosphamide for worsening of lupus nephritis. The patient underwent endotracheal intubation and mechanical ventilation, and computed tomography showed the presence of bilateral pulmonary infiltrates suggestive of DAH. Bronchoalveolar lavage was done and showed the presence of filariform larvae, morphologically consistent with Strongyloides stercoralis. Treatment with ivermectin was started and patient responded to treatment with improvement of clinical status. In conclusion, the development of SHS in patients with lupus, especially when receiving immunosuppressive therapy, is a severe and potentially fatal complication. Early detection and treatment may decrease mortality.

Highlights

Systemic lupus erythematosus is an autoimmune disease that causes potentially life-threatening flares
Case Reports in Medicine completes its asexual life cycle within its human host, with the potential to cause persistent infection leading to reinfection and what is known as a hyperinfection syndrome (HS)
The parasite invades the intact skin of its host, traveling via the lymphatic system to the venous system, which carries the parasite to the lungs

Summary

Introduction

Systemic lupus erythematosus is an autoimmune disease that causes potentially life-threatening flares. In 1904, Sir Osler suggested a pulmonary component associated with the disease [1] These pleuropulmonary manifestations have since been widely reported in the literature, with involvement affecting 50–70% of patients. SLE patients, those experiencing a flare-up, are treated with corticosteroids, which causes an immunocompromised state, putting these individuals at further increased risk for bacterial, fungal, and parasitic infections One such infection is that of Strongyloides stercoralis, which is endemic in tropical and subtropical regions. Completes its asexual life cycle within its human host, with the potential to cause persistent infection leading to reinfection and what is known as a hyperinfection syndrome (HS) This hyperinfection causes exacerbation of symptoms, those affecting the gastrointestinal and pulmonary systems [3].

Case Presentation

Discussion and Conclusions