Strongyloides Stercoralis Infection After the use of Emergency Corticosteroids

A Case Report on Hyperinfection Syndrome

George Vasquez-Rios; Roberto Pineda-Reyes; Eloy F. Ruiz; Angelica Terashima; Fernando Mejia

Disclosures

J Med Case Reports. 2019;13(121) 

In This Article

Case Presentation

A 61-year-old man from the Peruvian Amazon presented to the Emergency Department with a 1-week history of progressive shortness of breath, fever, and cough. His medical background was significant for essential hypertension and asthma. His home medications included lisinopril, fluticasone/salmeterol, ipratropium, and low-dose prednisone. He worked as a farmer in the Peruvian rainforest and had no known environmental exposure to pollutants or toxins. He did not smoke tobacco but he was a former alcohol user who quit drinking alcohol 5 years before presentation. He had a family history of hypertension. On evaluation, he was ill-appearing and in respiratory distress. His vital signs were: temperature (T) 38.2 °C, blood pressure 110/70 mmHg, heart rate 105 beats per minute (bpm), and respiratory rate 28 respirations/minute with saturation of oxygen (SO2) 87% on room air. Chest auscultation revealed diffuse wheezing and bilateral crackles. His cardiovascular examination showed tachycardia without gallops or murmurs. Furthermore, his neurological examination was negative for focal deficits or meningeal signs. The rest of the physical examination was unremarkable.

Initial laboratory results showed a white blood cell count of 34 × 109/L (bands 5%, lymphocytes 1.7%, eosinophils 0.3%). Biochemical analysis revealed hyponatremia, mild elevation of hepatic enzymes, and severe hypoalbuminemia. His arterial blood gases revealed: pH 7.28, partial pressure of carbon dioxide (pCO2) 55 mmHg, and partial pressure of oxygen (pO2) 59 mmHg. A chest X-ray showed bilateral base-predominant interstitial infiltrates concerning for community-acquired pneumonia (Figure 2). He was administered ceftriaxone and azithromycin, albuterol nebulization, and biphasic positive airway pressure support. In addition, a dose of prednisone (1 mg/kg) was administered orally for severe obstructive airway disease. He exhibited partial clinical improvement over the following 48 hours, but due to worsening oxygen requirements and persistent fever, his antibiotic therapy was switched to meropenem and vancomycin. Figure 3 shows a computed tomography (CT) scan with bilateral consolidations, predominantly on the lower lobe of his left lung.

Figure 2.

Chest X-ray showing bilateral interstitial infiltrates, predominantly in the bases

Figure 3.

Chest computed tomography scan revealing ground-glass opacities and interstitial infiltrates bilaterally, predominantly in the left side

On hospital day 5, he presented hemodynamic instability and acute encephalopathy, which prompted intubation and vasopressor support. Arterial blood gases showed: pH 6.9, pCO2 70.8 mmHg, and pO2 51 mmHg. His lactic acid level was 10.7 mmol/L. A repeat chest CT scan revealed extensive bilateral infiltrates and ground-glass opacities (Figure 4). Empiric therapy with micafungin was initiated. Bronchoalveolar lavage (BAL) was negative for conventional bacteria, fungi, or acid-fast bacilli. An extensive work-up was unremarkable including investigations for HIV and Human T-cell lymphotropic virus (HTLV-1), which were non-reactive. Considering the patient epidemiological background and his rapid deterioration despite broad-spectrum antibiotics, a new BAL was conducted to test for soil-transmitted helminths (STH). Fecal samples were collected as well. Finally, larvae of S. stercoralis were found in both BAL (Figure 5) and stool specimens (Figure 6). Corticosteroid therapy was discontinued and anti-parasitic treatment was started with ivermectin 200 μg/kg per day orally for 2 days. Therapy was repeated 2 weeks later to ensure adequate parasite eradication. Stool and bronchial specimens were negative thereafter. The patient experienced progressive recovery over the next 4 weeks. Unfortunately, he was lost to follow-up afterward.

Figure 4.

Repeat chest computed tomography scan showing diffuse interstitial infiltrates and consolidations

Figure 5.

Strongyloides stercoralis larvae found in bronchoalveolar lavage

Figure 6.

Strongyloides stercoralis larvae found in stool examination

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