C48-08 From Soil to Circuit: Veno-Venous ECMO in Strongyloides Hyperinfection Syndrome

Abstract Introduction Strongyloidiasis is a parasitic infection endemic to tropical and subtropical regions, and one that is usually asymptomatic in immunocompetent individuals, where the only indication of infection may be peripheral eosinophilia. Common presentations of acute Strongyloides stercoralis infection usually consist of gastrointestinal symptoms, and can be accompanied by respiratory symptoms and characteristic serpiginous rash as well, which can be treated effectively with single or multiple doses of therapy. At the end of the spectrum of strongyloidiasis lies strongyloides hyperinfection syndrome (SHS), which is characterized by an exponential increase in parasitic burden and subsequent multiorgan involvement, typically precipitated by immunosuppression and is often fatal despite aggressive treatment. Case The patient is a 34-year-old woman from Haiti who presented to the ED with recurrent abdominal pain, nausea, and vomiting. Physical exam notable for diffuse abdominal pain to palpation, with mild guarding and distention. Labs were notable for WBC 32.6, 75% neutrophils, with mildly elevated eosinophil count 0.7. On CT scan, she was found to have small bowel obstruction and enterocolitis, and underwent exploratory laparotomy with lysis of adhesions. Post-extubation, she experienced aspiration and acute hypoxic respiratory failure (AHRF) requiring re-intubation. Her course was further complicated by shock, and she was given steroids for concern for ARDS. She had increasing difficulty with oxygenation and ventilation. Chest x-ray demonstrated diffuse bilateral airspace disease. She underwent bronchoscopy which revealed bloody secretions, patent airways without evidence of tracheobronchial mucosal injury. She remained persistently hypoxic despite optimization of mechanical ventilation, and was ultimately cannulated for Veno-Venous-ECMO on day 4 of hospitalization. Four days later, physical exam showed progressive petechial and purpuric skin lesions most prominently involving her abdomen. A skin biopsy was obtained, which showed nematode larva favoring strongyloides, and the identification of strongyloides larvae in tracheal aspirate culture further confirmed the diagnosis. Further work up revealed she had undiagnosed HTLV-1 infection. She received subcutaneous ivermectin and albendazole for SHS. She subsequently had resolution of AHRF and shock, and survived to decannulation from ECMO on day 19. Discussion Strongyloides hyperinfection syndrome is a serious complication of otherwise usually asymptomatic parasitic infection, that may initially present with abdominal manifestations, and progress to severe respiratory and cutaneous manifestations. Clinicians should maintain a high index of suspicion for SHS in patients from endemic areas, underlying immunocompromised states, and recent administration of steroids. This case demonstrates the feasibility of Veno-venous ECMO as supportive therapy, marking the first documented survival to decannulation. This abstract is funded by: None