The Gift of a Heart, With Strings Attached: A Case of Strongyloides Stercoralis Hyperinfection Syndrome With Fulminant Respiratory Failure

Document Type

Conference Proceeding

Publication Date

5-21-2024

Publication Title

Am J Respir Crit Care Med

Abstract

Introduction: Strongyloides stercoralis is an intestinal nematode, endemic to tropical and temperate regions, including the Appalachian region of the southern United States. An estimated 600 million is people infected worldwide1. While most infections are asymptomatic, in immunocompromised patients, particularly from steroid use, it has the potential to cause a highly fulminant and potentially deadly hyper-infection syndrome2. Case Description: A 43-year-old woman with a history of orthotopic heart transplant for nonischemic cardiomyopathy, steroid-induced diabetes, and recent hospital admission for Escherichia Coli bacteriemia of unclear source, was readmitted with persistent fatigue, lethargy, generalized weakness, nausea, non-bloody emesis and shortness of breath. Immunosuppressive regime included prednisone, tacrolimus, and mycophenolate mofetil. She was afebrile, tachycardic and hypotensive, tachypneic and hypoxic, requiring 6L of supplemental oxygen. Laboratory findings included hemoglobin of 6.9g/dL, normal white blood cell count and differential, anion gap metabolic acidosis with hyperglycemia, and elevated amylase at 1081 IU/L. SARS CoV2 was not detected. CT scan of the chest and abdomen revealed acute pancreatitis, extensive ground glass, and consolidative opacities in both lungs. Echocardiography showed hyperdynamic ejection fraction. She was treated for diabetic ketoacidosis secondary to acute pancreatitis and sepsis from pulmonary source. Noninvasive infectious evaluation was negative. Respiratory failure worsened, requiring mechanical ventilation and extracorporeal membranous oxygenation. Repeat chest imaging revealed bilateral dense consolidation with air bronchograms, and smooth septal thickening without pleural effusions. Bronchoscopy confirmed diffuse alveolar hemorrhage, with live Strongyloides organisms on cytology (Figure 1). Notably, transplant coordinators were informed of Strongyloides infection in a kidney recipient from the same donor. She received ivermectin and eventually recovered after a prolonged hospital course. Discussion: Strongyloides hyperinfection occurs from acceleration of the organism's auto-infective life cycle from host T-cell mediated immunosuppression. Increased parasite burden and migration between the gastrointestinal and pulmonary system often occur with enteric gram-negative bacteremia and can lead to alveolar hemorrhage and fulminant pneumonitis3. Conclusions: Strongyloides hyperinfection is potentially fatal and underrecognized. It should be considered in patients who are immunosuppressed, with unexplained enteric gram-negative bacteremia and fulminant respiratory failure. Recipients of organ transplants and organ donors should be routinely screened for Strongyloides infection. (Figure Presented).

Volume

209

Issue

9

First Page

A1134

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