#1:69–year–old female Chinese immigrant with rheumatoid arthritis on prednisone and methotrexate presented with weakness, abdominal discomfort, cough, fever and chills. She developed sepsis with bilateral lung opacities. Endoscopic biopsy revealed Strongyloides stercoralis. #2:72–year–old male Cuban immigrant with emphysema, lumbosacral plexopathy, and recent exposure to steroids was admitted with increasing dyspnea. He developed sepsis with bilateral interstitial infiltrates and respiratory failure. Bronchoalveolar lavage revealed S. stercoralis. #3:70–year–old female from Puerto Rico with lupus nephritis and recent initiation of prednisone, presented with weakness, anorexia, and rash over the chest and abdomen. Hospital course was complicated by respiratory failure and sepsis. Skin biopsy of the non–blanching, purpuric, and petechial rash showed S. stercoralis larvae. #4:45–year–old female from China recently diagnosed with lupus nephritis on prednisone and mycophenolate mofetil, presented with weakness and progressive dysphagia. She developed sepsis and respiratory failure. Computer tomography (CT) showed bilateral pneumothoraces, pneumomediastinum, and ground–glass opacities. Bronchoscopy revealed diffuse alveolar hemorrhage and filariform larvae consistent with S. stercoralis. #5:56–year–old male from Dominican Republic with multiple myeloma treated with dexamethasone, melphalan, and thalidomide presented with leg weakness. After radiation therapy for bone lesions, he developed gastrointestinal complaints and sepsis. CT chest showed extensive ground–glass opacities. Bronchoalveolar lavage showed filariform larvae consistent with S. stercoralis. We describe five cases of hyperinfection in patients from endemic regions that were due to immunosuppressive agents. Three of five did not survive.
Strongyloides stercoralis, an intestinal nematode endemic to tropics and subtropics, affects 30–100 million people worldwide. It may be asymptomatic, however hyperinfection has a mortality reported as high as 85%. The presence of sepsis or fever with any level eosinophil count, anorexia, bloating, weakness, or wheezing in a patient from an endemic area or who is immunosuppressed should prompt testing for S. stercoralis. Practitioners planning on prescribing medicines that will affect immune status must be aware of this potential complication and consider screening prior to starting treatment.
S. Stecoralis infection has a high morbidity and mortality. Incidence may be rising due to immunosuppressive and chemotherapeutic medication use, the prevalence of immunecompromized patients, and more global travel. Early detection and treatment is crucial to avoid systemic manifestations including death. Consideration should be given to creating guidelines for screening and prophylaxis in high–risk populations.