The unwelcome guest: a case of strongyloides stercoralis hyperinfection in a patient with steroid-dependent asthma-copd overlap syndrome (acos)

SESSION TITLE: Unusual Chest Infections 2 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Strongyloides stercoralis is a soil transmitted roundworm nematode estimated to affect over 600 million people worldwide. Hyperinfection syndrome (HS) has been described in immunosuppressed patients. The increase in parasitic burden leads to tissue invasion and disseminated disease . Recurrent bloodstream infection and pulmonary involvement are of high clinical concern. Our case highlights a rare manifestation of HS due to Strongyloides stercoralis causing acute respiratory failure in an asthma-COPD overlap syndrome (ACOS) patient on chronic corticosteroid therapy. CASE PRESENTATION: A 63-year-old woman with diabetes, chronic obstructive pulmonary disorder due to chronic cigarette smoking and severe asthma on chronic prednisone therapy presented to the emergency department (ED) with recurrent intractable abdominal pain and shortness of breath. Patient had been reporting severe and progressive weakness for the preceding two months leading to functional quadriplegia initially attributed to steroid-induce myopathy. Initial blood work reveals hypothyroidism and thyroid replacement therapy was started. Due to clinical presentation, a computed tomography (CT) of abdomen and pelvis with IV contrast was performed which raised concern for gastroenteritis and possible liver abscesses. Patient underwent esophagogastroduodenoscopy (EGD) showing friable mucosa and gastric mucosa biopsies were obtained. A Chest CT with intravenous contrast was obtained and revealed bilateral multifocal ground glass opacities (Figure 1). Patient deteriorates with progressive acute hypoxic respiratory failure and acute metabolic encephalopathy requiring invasive mechanical ventilation. Tissue biopsy, returned positive for Strongyloides stercoralis infection (Figure 2,3). Dual anti-parasitic therapy with Ivermectin and Albendazole was initiated due to concerns for disseminated disease. Bronchoscopy visualized purulent secretions in the left bronchial tree and bronchoalveolar lavage was positive for Pseudomonas aeruginosa prompting antibiotic coverage. Lumbar puncture was non-contributory. Patient was treated for septic shock with vasoactive medications and IV stress dose hydrocortisone which were weaned over one week. Patient was successfully extubated and was discharged from the hospital to a rehabilitation center without steroid therapy. DISCUSSION: Due to the classic transmission and life cycle of the filiform larvae, the lungs are target organs in (HS). Chronic corticosteroid therapy dependence, as seen in many patients with difficulty-to-treat pulmonary disease and ACOS, carry a higher risk of HS due to immunosuppression. Early diagnosis and prompt treatment are crucial to prevent the progression of the disease, The mortality of HS ranges from 85-100% when untreated. In our case, the lack of peripheral eosinophilia, explained by chronic steroid use, masked initial suspicious for parasitic infection, and disseminated disease proven the need for life-support interventions. The institution of dual antiparasitic and bacterial-associated infection in conjunction with critical care medicine supportive measurements allowed for our patient to be discharge to acute rehabilitation. CONCLUSIONS: Hyperinfection Syndrome due to Strongyloides stercoralis carries a high risk for disseminated infection in patients on chronic steroids. High index of suspicious, tissue sample, and prompt institution of target therapy institution are key for a successful clinical outcome. REFERENCE #1: Czeresnia JM, Weiss LM. Strongyloides stercoralis. Lung. 2022 Apr;200(2):141-148. doi: 10.1007/s00408-022-00528-z. Epub 2022 Apr 9. PMID: 35396957; PMCID: PMC8994069. REFERENCE #2: Nutman, Thomas B. "Human infection with Strongyloides stercoralis and other related Strongyloides species." Parasitology, vol. 144, no. 3, 2017, pp. 263-273. Cambridge University Press, doi: 10.1017/S0031182016001842. REFERENCE #3: Buonfrate, Dora et al. "Severe strongyloidiasis: a systematic review of case reports." BMC Infectious Diseases, vol. 13, 78, 2013, BioMed Central, doi: 10.1186/1471-2334-13-78. DISCLOSURES: No relevant relationships by Waleed Aldadah No relevant relationships by Christian Almanzar Zorrilla No relevant relationships by Ruben Cabrera No relevant relationships by Mauricio Danckers No relevant relationships by Raiko Diaz No relevant relationships by Sarah Honeycutt No relevant relationships by Manjot Malhi No relevant relationships by Rafael Miret No relevant relationships by Kishankumar Patel No relevant relationships by Jennifer Perez No relevant relationships by Alfredo Toll No relevant relationships by Daniel Zapata