Fatal Strongyloides stercoralis Hyperinfection in a Patient With Gastrointestinal Bleeding and Asthma: A Case to Screen for Asymptomatic Carriers

Introduction: This is a rare case of hyperinfection syndrome secondary to Strongyloidesstercoralis infection presenting with GI bleeding. Presentation: This is the case of a 90-year-old female, who immigrated from Laos 30 years prior, with a history of atrial fibrillation on pradaxa, uncontrolled asthma of 20 years, requiring intermittent steroids, who used to work on a farm, and presents with GI bleeding. She had several days of nausea, malaise, and an episode of bloody emesis. In the ED, she had melena mixed with red blood and a Hb of 9.9 g/dL, hypotension, received pradaxa-bind, and underwent prompt EGD and flexible sigmoidoscopy. The findings were severely inflammed and friable mucosa of the duodenum, gastric antrum and esophagus with patchy erythema of the sigmoid colon (see images). Subsequently, two out of two sets of blood cultures were positive for E. coli. The pathology revealed a high parasitic load of Strongyloides stercoralis. She was started on ceftriaxone and ivermectin, did not improve, and went to hospice. Discussion:Strongyloides stercoralis is a threadworm endemic to tropical areas. Risk factors include working with soil contaminated by human feces. Acute strongyloidiasis involves filariform larva that enter the skin causing local reactions, ascend the tracheobronchial tree causing tracheal irritation and cough, and descend the GI tract causing multiple GI manifestations. Patients with chronic strongyloidiasis can remain asymptomatic up to 75 years. Hyperinfection syndrome refers to an accelerated reproduction of larvae in a colonized host due to alteration of the immune system. It can be complicated by bloodstream infections due to GI mucosal inflammation and hematogenous spread. This patient presented with gastrointestinal bleeding, which is rare. The patient's diagnosis of asthma may have been a manifestation of chronic strongyloidiasis. Subsequent treatment with steroids may have led to hyperinfection syndrome. Retrospectively, it was found that this patient had a positive Strongyloides IgG antibody. While not specific, a positive serologic test in a patient whose history correlates with stronglyloides infection may warrant empiric treatment. Screening has been suggested for individuals with risk factors who are likely to be placed on immunosuppressive therapies. We propose routine screening for individuals with risk factors who will require immunosuppression in order to reduce the risk of developing hyperinfection syndrome.2037_A Figure 1. Friable mucosa of the 2nd part of the duodenum. Underlying biopsy showed duodenal mucosa with villous blunting, increased active chronic inflammation and reactive epithelial changes.2037_B Figure 2. Patchy erythema of the sigmoid colon seen on flexible sigmoidoscopy. Underlying biopsy showed colonic mucosa with moderate active colitis and reactive epithelial hyperplasia. Focal parasites were identified suggestive of Strongyloides stercoralis morphology.

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