Strongyloides stercoralis Causing Polymicrobial Empyema in a Cancer Patient

Hung D. Tran, MD, Sinai Hospital, Baltimore; John N. Greene, MD, and Ramon L. Sandin, MD, MS, both from the University of South Florida College of Medicine and H. Lee Moffitt Cancer Center and Research Institute, Tampa; and Albert L. Vincent, PhD, H. Lee Moffitt Cancer Center and Research Institute, Tampa

Disclosures

Infect Med. 2001;18(1) 

In This Article

Case Report

A 46-year-old man from Apollo Beach, Fla, with no history of travel outside of the United States, underwent a resection of a right chest wall sarcoma with flap reconstruction. Surgery was followed by chemotherapy with methotrexate, doxorubicin, ifosfamide, and dacarbazine and local chest wall radiation treatment. Subsequently, purulent drainage developed from the wound site, and the patient was given intravenous penicillin and gentamicin. Culture of the drainage material grew Pseudomonas aeruginosa and an Enterococcus species, and the patient was switched to treatment with intravenous piperacillin. He was discharged within 1 week of admission and was readmitted 3 days later to undergo a total resection of the right clavicle. Culture of harvested material grew Staphylococcus epidermidis and, again, P aeruginosa. A 10-day course of trovafloxacin postoperatively was begun. Because the patient failed to improve, he was readmitted for intravenous antibiotic therapy. The P aeruginosa isolated from the purulent drainage of the chest wound site was resistant to quinolones.

On examination, the patient was afebrile and not in acute distress. His lungs, heart, and abdomen were unremarkable except for decreased breath sounds on the right side. The flap on the right side of his chest wall had healed well, but on the medial aspect of his old clavicular site, there appeared a 1-cm orifice draining tan-colored purulent material. Edema of the right upper extremity was chronic and unchanged.

Laboratory findings showed a leukocyte count of 7000/µL (normal, 4000 to 10,900/µL) with a normal differential and with no eosinophilia, a hematocrit level of 25% (normal, 34.3% to 45.4%), hemoglobin level of 8.3 g/dL (normal, 11.4 to 15 g/dL), and a platelet count of 204,000/µL (normal, 143,000 to 382,000/µL). Electrolyte and liver enzyme levels were normal except for a slight elevation of the alkaline phosphatase level.

CT of the chest confirmed the presence of 2 separate fluid collections in the right side of his chest, 1 anterior and the other posterior. Large-bore catheters were introduced into the right hemithorax to drain both collections. Cultures from the right anterior lung grew Enterococcus species and P aeruginosa. An unexpected finding from a viral culture from the right posterior lung was the filariform larva of S stercoralis (Figure 1). In addition, the pleural fluid was submitted to a comprehensive series of stains and cultures that were all negative for viruses; fungi; and bacteria, including anaerobes, mycobacteria, Nocardia, and Legionella. Fecal specimens and sputum were likewise negative for ova and parasites.

Rhabdoid larva of Strongyloides stercoralis as seen on a viral shell vial culture.

A 3-day course of oral albendazole, 400 mg/d; cef-epime, 2 g intravenously every 8 hours; and vancomycin, 1 g intravenously twice daily, was begun. CT scans repeated 1 week after treatment showed no marked changes in the right pleural fluid collections, and intrapleural urokinase was instilled to break up the loculations in order to improve drainage and lung reexpansion. After 5 days, the patient improved, with gradual decrease in the size of the hydropneumothoraces. Treatment with cefepime and vancomycin was continued for 6 weeks after discharge. Penrose drains in the chest were left in place to create a pleural-cutaneous fistula for chronic drainage. Several courses of antibiotics were required because of chronic drainage of the chest tube site with persistence of multidrug-resistant P aeruginosa. Several weeks later, metastasis of the sarcoma to the brain required surgical resection followed by local brain irradiation. The patient remained asymptomatic without taking antibiotics and with continued chest tube drainage until he died of metastatic sarcoma, with no evidence of recurrent Strongyloides infection.

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