Purpose: A previously healthy 24-year-old Liberian female presented to the ED with a one week history of worsening crampy abdominal pain. Review of systems was notable for nausea, vomiting, fevers, and chills, as well as dyspnea. Past medical history was significant for Strongyloides stercoralis infection diagnosed histologically via EGD in 2008. She was then treated with ivermectin. The patient had lived in the USA for 9 years and had no history of recent travel or pet exposure. On examination, the patient was febrile, tachycardic, tachypneic and hypoxemic. Her abdomen was diffusely tender; pulmonary exam was significant for scattered bilateral crackles. Chest CT revealed pulmonary vascular congestion/edema. Initial labs included a WBC of 14.9 k/uL with bandemia; she eventually developed eosinophilia. Serum immunoglobulins were normal and HIV/Hepatitis B/C tests were negative. Strongyloides IgG Ab was 1.76, suggestive of possible infection. The patient was admitted to the ICU and intubated for hypoxia. EGD showed severe diffuse duodenal inflammation and mucopurulent exudate. Duodenal biopsies revealed heavy S. stercoralis infection and mucosal ulcerations/microabscesses; stool samples contained Strongyloides larvae. The patient was treated with ivermectin and albendazole. She developed ARDS but recovered and was eventually discharged. She completed six monthly doses of ivermectin. Follow-up stool samples were negative for larvae. Endemic not only to tropical/subtropical regions but also to the southeastern USA, S. stercoralis is an intestinal nematode that can replicate within humans leading to ‘autoinfection.' Peripheral eosinophilia is present in 50-80% of cases. Most cases in immunocompetent individuals result in chronic, asymptomatic infection. Generally, disseminated ‘hyperinfection' occurs in individuals with altered immune systems (corticosteroid use, HIV, HTLV-1 infection, lymphoma, diabetes, chronic alcohol use, or malnutrition). Severe infection is rare but carries a case-fatality rate near 60%. This patient developed disseminated Strongyloidiasis with severe pulmonary and gastrointestinal manifestations in the absence of any traditional risk factors. This case shows that Strongyloidiasis must be considered in patients with gastrointestinal symptoms and eosinophilia, especially with history of travel to an endemic region.Figure