A CASE OF STRONGYLOIDES IN AN IMMUNOCOMPROMISED PATIENT P Soto Justiniano MD, C Michael MD, M Eschete MD Department of Internal Medicine, Leonard J Chabert Medical Center, Houma, LA
INTRODUCTION Infections due to Strongyloides stercoralis are prevalent in rural areas of tropical and subtropical regions, and cases in the United States are more common in the Southeast. Immunocompromised hosts with HTLV-1, HIV/AIDS, malignancy, congenital immunodeficiency, or alcoholism are at an increased risk of developing disseminated disease, and are more prone to atypical presentations. CASE: A 44-year-old man with HIV presented with arthralgias, myalgias, and fevers. He reported pain in his knuckles and toes that started one day after re-initiating antiretroviral therapy (ART) (Dolutegravir/Lamivudine), and concomitantly noted a cough and sore throat. Computed Tomography (CT) chest showed focal consolidations in bilateral lobes, mediastinal lymphadenopathy, and splenomegaly. Studies were negative for Legionella and Streptococcal antigens and Mycoplasma antibodies. The patient was treated for community acquired pneumonia, and his antiretroviral medication was held. As he continued to have polyarthralgia despite holding ART, the medication was then resumed. Two weeks post discharge, and four days after resuming ART, the patient developed fever, chills, fatigue, and a productive cough with brown-grey sputum. Labs were significant for: ESR 42, CRP 86.1, and a positive ANA screen; however the ANA profile/pattern/titers, Rheumatoid factor, Fungal immunodiffusion test, Quantiferon Gold, and AFB sputum cultures were negative. The patient was transitioned from his ART to Biktarvy, and was referred to Pulmonology. The patient was noted to have a peripheral eosinophilia. Workup included: CCP, ANCA, Aspergillus IgE, and stool O&P, which were negative. Bronchoscopy showed a Staphlococcus aureus infection, but despite appropriate treatment, his cough and debilitating arthralgias persisted. The last study was Strongyloides IgG antibody which was positive. Treatment was initiated with Ivermectin for disseminated strongyloidiasis. Within four weeks, the patient’s symptoms resolved, eosinophilia trended down, and Chest CT improved. DISCUSSION: With a mortality rate of 70-100%, higher rates being in disseminated disease, Strongyloidiasis is not to be overlooked. While eosinophilia can be observed, it is often absent in disseminated disease. Patients often present with gastrointestinal, pulmonary, and cutaneous manifestations. Less commonly, nephrotic syndrome, GI bleeding, ascites, hepatic lesions, and arthritis can be seen. Early treatment ensures the highest chances for survival.
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