Strongyloidiasis in a Hyperinfected Patient

Case Presentation A 69-year-old man was hospitalized due to increasing difficulty in breathing and cough. During previous hospitalizations, he had been treated for arteriosclerotic vascular disease with myocardial infarction and chronic obstructive pulmonary disease (COPD). His COPD now was found to be acutely exacerbated, so he was treated with 60 mg of methylprednisolone. The patient complained of intermittent episodes of diarrhea and shortness of breath, which did not always occur concurrently. The patient was a veteran who had served in the South Pacific in the 1940s and Vietnam in the 1960s. A complete blood count with differential revealed an increased white blood cell count (18.5X10/L [18,500 cells/uL]) and an elevated eosinophil count (0.06 [6%]) on admission. However, subsequent eosinophil counts fell to within normal range (0-0.02 [0%-2%]). A week after the patient's admission, a Gram's stain and culture of a routine sputum specimen were found to be unremarkable, except for an unusual displacement of bacterial colonies on the primary culture media. On his 11th day in the hospital, the patient experienced a significant drop in his hemoglobin (76 g/L [7.6 g/dL]) and hematocrit (0.22 [22%]); a stool specimen was negative for occult blood. A second sputum sample submitted for a routine Gram's stain and culture exhibited roundworm larvae on the smear (Fig 1) and significant bacterial displacement on the primary culture media (Fig 2). Because the patient's bowel was obstructed, stool specimens were not available. A nasogastric aspirate, therefore, was obtained via a nasopharyngeal tube for a direct wet mount. The examination demonstrated three stages of the roundworm Strongyloides stercoralis (Fig 3). Tests for gastric and fecal occult blood were positive 2 to 3 weeks after admission; blood cultures (4 sets) were negative. A purpuric rash developed on the patient's lower extremities and spread upward to his abdomen. Although he was treated with thiabendazole, his condition continued to deteriorate, and he died of strongyloidiasis 32 days after admission. The autopsy revealed numerous small foreignbody granulomas and necrotic material throughout the lungs and small bowel mucosa. The necrotic material may have been larvae of the genus Strongyloides but could not be identified definitively as such because the necrosis was pervasive.