Case Presentation: A 71-year-old man with left pelvic kidney and complicated genitourinary history underwent a subtotal cystectomy with ileal conduit placement. Post-operative course was unremarkable. Two days after discharge, he was admitted with fever and abdominal pain. Physical exam showed purulence from the stoma. CBC demonstrated 11,500 WBC with 8300 neutrophils and 800 eosinophils. Urine culture from the ileal conduit grew Klebsiella. The patient was treated with ceftriaxone and was discharged. Four weeks later, he was admitted again with fever and abdominal pain. Physical exam demonstrated left lower quadrant tenderness and a healthy right lower quadrant stoma. CBC now demonstrated 16,500 WBC with 12,500 neutrophils and 1200 eosinophils. Blood, urine, and stool cultures were sent. Abdominal CT demonstrated acute pyelonephritis of the left kidney. Patient was started on ceftriaxone. Microbiology lab requested an additional urine sample given an unusual element noted on the original sample. Repeat urine microscopy confirmed presence of small worms, identified as Strongyloides. Stool O&P exam confirmed presence of the same. The patient did not have any signs of disseminated disease, including no rash or pulmonary infiltrates. He was diagnosed with local Strongyloides isolated to the GI tract. Patient was treated with ivermectin for five days and improved. Additional history obtained during the third hospitalization revealed that patient had spent extensive time in Puerto Rico in the year prior to his bladder surgery.
Discussion: Stronglyoides stercolaris is a roundworm responsible for strongyloidiasis in humans. Endemic to rural tropical and subtropical regions, it can also be found in temperate areas. Typically, larvae penetrate the skin via contact with soil or human feces. They then enter the venous system and transfer to alveoli. The larvae then ascend the bronchi where they are coughed up and swallowed. In the GI tract, they mature into adult worms that reproduce and establish a parasitic infection in the duodenum and ileum. New larvae then pass in feces to complete the life cycle. Occasionally, Strongyloides can cause auto-infection where larvae mature to their infective forms in the GI tract, then penetrate through the colonic mucosa or perianal region, resulting in disseminated disease. Disseminated strongyloides can cause fever, cough, hemoptysis, diarrhea, and urticaria. Pulmonary infiltrates may be seen on chest X-ray. In our patient’s case, the patient’s symptoms were likely due to a non-disseminated infection. The patient likely harbored a chronic GI infection that manifested itself in the setting of the ileal conduit surgery due to juxtaposition of the infected ileum to the kidney.
Conclusions: While not seen in all cases of strongyloidiasis, the presence of eosinophilia could have alerted clinicians to the possibility of a parasitic infection and may have led to an earlier diagnosis.