Case Presentation:

A 58‐year‐old Laotian man with a medical history of diabetes mellitus, hypertension, and asthma presented with confusion, fever, and a rash. Review of systems was remarkable for abdominal discomfort in the preceding days without change in bowel habits. He had emigrated from Laos in 1979 and had no recent travel history. His vital signs revealed that he was febrile (40.6°C), tachycardic (136), and tachypneic (32), with normal oxygen saturation on room air. He was ill‐appearing, confused, and uncooperative. There were no murmurs on cardiac exam, his lungs were clear to auscultation, and his abdominal exam was benign. Skin exam was notable for a red macular rash over his trunk, buttocks, and all extremities. Laboratory values were significant for the following: lactic acidosis (4.7), transaminitis (AST 266, ALT 224), but no leukocytosis (9.7). CSF cell count from lumbar puncture (LP) showed 4200 WBCs with 100% PMNs; protein 365 mg/dL; and glucose 76 mg/dL. Glycosylated hemoglobin (HgbA1c) was 12.4. Prior to the LP, steroids, and antibiotics were begun, and a head CT scan (normal) was obtained. The patient was admitted to the intensive care unit (ICU) with a diagnosis of bacterial meningitis and sepsis, and broad‐spectrum antibiotics were continued. As the patient's mental status worsened, he was intubated for airway protection. CSF and blood cultures grew Streptococcus bovis. Subsequently, the patient developed eosinophilia. A nurse noted a piece of “stringy” material in the patient's stool, described as looking like “pulled pork” and sent it to the laboratory, where it was identified as Strongyloides stercoralis. The patient was treated with ivermectin. After several weeks in the ICU, the patient's condition stabilized, his mental status gradually improved, and he was extubated. Eventually he was transferred to a rehabilitation facility, where his health returned to baseline prior to discharge home.


Strongyloides stercoralis is a helminthic parasitic infection that can establish residency in humans and remain asymptomatic for decades because of its autoinfective life cycle. It is predominantly located in tropical regions of the world but is also present in the southeastern United States. Bacterial complications may occur and are most often secondary to bowel wall disruption and bacterial translocation. Four previous case reports of concomitant S. bovis infections and Strongyloides have been published with only 1 known to be in an immunocompetent patient. Diabetes mellitus has recently been shown to be a risk factor for Strongyloides seropositivity in areas of high prevalence, and other case reports have associated DM with hyperinfection syndrome.


This case illustrates an unusual complication (Streptococcus bovis meningitis) of a disease not commonly seen (Strongyloides stercoralis hyperinfection) in the United States in a Southeast Asian immigrant with poorly controlled diabetes mellitus.

Author Disclosure:

D. Ricci, none; R. Nabar, none; P. Aronowitz, none.