Case Presentation:

A 91-year-old Puerto Rican female presents with a productive cough for 3 weeks and progressively worsening shortness of breath for 1 week. Over the course of 1 year she was admitted to the hospital twice, presented to the ED 4 times, and had numerous visits with her primary care physician for the same clinical picture. Each time she was diagnosed with asthma/COPD exacerbation and given high dose IV or oral steroids and ipratropium bromide-albuterol sulfate nebulizers. The patient had a history of asthma, hypertension, hyperlipidemia, and diabetes. Her social history was significant for relocating from Puerto Rico 3 years ago and smoking tobacco for 4 years but quit over 10 years ago. Her physical exam was only remarkable for end-expiratory wheezing. Chest X-ray was negative for acute pulmonary disease. Labs including WBC and BMP were within normal limits. Eosinophils of 28% were noted on the differential. By day 2 of admission, she still had not clinically improved with standard asthma exacerbation management so differential was broadened. Aspergillus IgG/IgE, serum IgE, and Strongyloides IgG were sent. Serum IgE was elevated to 836 KU/L, and Strongyloides IgG was positive. She was treated with ivermectin, and her symptoms improved.


Strongyloides is endemic in tropical and subtropical regions, including Puerto Rico. Patients can present with gastrointestinal, pulmonary, and skin manifestations, but GI symptoms are the most common. However patients can present solely with respiratory symptoms. Symptomatic pulmonary strongyloidiasis that results from migrating larvae is observed in 10% of patients, who are usually immunocompromised. Symptoms include dry cough, throat irritation, hemoptysis, dyspnea, or acute respiratory distress syndrome. Because pulmonary symptoms are similar to those of asthma and COPD, physicians often treat the patients with steroids. Steroids impair cellular immunity and are considered a risk factor for disseminated strongyloidiasis, which is associated with severe morbidity and mortality. A survey showed that US physicians-in-training had lack of ability to recognize the need for parasite screening (9%), and 41% of participants were incapable of recognizing parasitic pulmonary manifestations. 


This is a notable case of strongyloides in an immunocompetent patient who may have been brushed off by many providers in the past as having uncontrolled asthma. This patient reported a history of asthma since childhood which may have delayed her diagnosis of strongyloidiasis. This diagnosis should be considered in patients who have exposure in disease-endemic areas and history of poorly controlled reactive airway disease. This case emphasizes the importance of a detailed history and the development of wide but relevant differential diagnosis. We are used to seeing horses, but it is important to be able to recognize a zebra in the herd.