Fatal Disseminated Strongyloidiasis Secondary to Corticosteroid Use: A Report of Two Cases
Strongyloides stercoralis is an intestinal nematode endemic to tropical and subtropical locations, such as most of Latin America, and in the United States, the Appalachian mountain region. Clinical manifestations vary greatly and are non-specific; as a result, cases in regions that do not regularly screen for strongyloides often go undiagnosed. Current research estimates a prevalence of 370 million cases worldwide. Chronically infected patients that become immunosuppressed, particularly from exposure to corticosteroids, are at risk for developing a hyperinfection syndrome or disseminated strongyloidiasis, which carries a mortality rate of up to 87%. We present two cases of fatal disseminated strongyloidiasis. The first case is that of a 66 year old man, originally from Nicaragua, with ulcerative colitis receiving corticosteroids for three months that developed fatal disseminated strongyloidiasis which was complicated by gram-negative bacteremia, a complication associated with the highest mortality rates. The hospital course was additionally complicated by cytomegalovirus infection, Clostridium difficile colitis, severe gastrointestinal bleeding, disseminated intravascular coagulopathy, deep venous thromboses, pulmonary emboli, fungemia, bacterial meningitis, multifocal pneumonia with aspergillosis and toxic megacolon. The second case is that of an 87 year old man, originally from Cuba, with chronic obstructive pulmonary disease (COPD) and pulmonary fibrosis on corticosteroids for an unknown duration that developed fatal disseminated strongyloidiasis. The hospital course was complicated by respiratory failure, anemia and thrombocytopenia, atrial fibrillation with heart failure, acute renal failure, lactic acidosis, alveolar hemorrhage and Mycoplasma pneumoniae pneumonia. Both patients were originally from Latin American countries where strongyloides is endemic. Because chronic infections are typically asymptomatic, both were likely unaware they were infected. Furthermore, use of corticosteroids suppresses the eosinophilic response to infection, which is often the only clinical evidence that prompts clinicians to search for strongyloides. These cases highlight the importance of screening patients from endemic areas prior to initiation of immunosuppressive therapy.