Case Presentation: A 24 year old Hispanic male with history of ESRD due to presumed medullary cystic disease who underwent DDKT x2 first in 2/2011 complicated by acute vascular rejection with loss of transplant, then again in 11/2011 which was complicated by antibody mediated rejection in 2015 that was treated with plasmapheresis developed a subacute onset of dry cough for 3 weeks and intermittent fevers intermittent nausea, vomiting and diarrhea for 2 weeks. He presented to ED and was found to have acute kidney failure with serum creatinine of 5.9 (baseline 0.9) and BUN of 62. Other significant labs were WBC 11.4k/uL with 7% Eosinophil, with absolute eosinophil count of 800/uL as well as eosinophils being noted in his urine. He was admitted with a concern for acute rejection of his renal transplant and his symptoms quickly resolved with supportive treatment. Infectious work up with blood cultures, CT chest, EBV and CMV returned negative. Stool PCR study was positive for EPEC. Given his history of being born in Mexico as well as the plan for significant immunosuppression, Stongyloides antibodies and stool studies were requested. On hospital day 3, given continued renal dysfunction he was started on methylprednisolone 250mg daily for 3 days for treatment of acute rejection of transplanted kidney with plan to start thymoglobulin after that. On hospital day 5 Strongyloides antibody returned positive. He confirmed no travel to any endemic regions for over 8 years. Thymoglobulin initiation was held and he was started on iv ivermectin for 7 days with complete resolution of his symptoms. Following this course of ivermectin treatment, he received thymoglobulin and his renal function improved.

Discussion: Strongyloides Stercolis is a nematode common tropical infection but rarely seen in US. It is often seen in immigrants from endemic areas like Brazil, Thailand, Mexico, and India. The primary means of infection is through contact with the helminth in soil. The majority of people infected with strongyloides do not have any symptoms, however if symptoms develop, they are often non-specific and generalized including abdominal pain, diarrhea, dry cough and rashes. Given that many infections are subclinical and asymptomatic, chronic infection can occur and are associated with peripheral eosinophilia. Notably, strongyloidiasis can be severe and life threatening in patients who are immunosuppressed or are transplant recipients. Our patient had previously lived in an endemic area and presented with nonspecific pulmonary and GI symptoms, as well eosinophilia in the setting of being immunosuppressed, all of which raised the concern for Strongyloides. Given the need for very aggressive additional immunosuppression to treat his acute transplant rejection, this was an important diagnosis to rule out due to the possibility of precipitating a Strongyloides hyperinfection syndrome. In this, a massive release of parasites from the GI tract occurs, that often leads to overwhelming sepsis and even death.

Conclusions: Chronic Strongyloidosis is commonly subclinical and asymptomatic but patients can develop nonspecific generalized complaints that mimic asthma, COPD or IBD. Eosinophilia may be absent in 27% of cases and stool studies are not very sensitive thus limiting its diagnosis. High clinical suspicion is important in immunocompromised patients to avoid disseminated strongyloidosis or hyperacute syndrome which can be fatal.