Abstract Introduction Loeffler’s syndrome is a transient pulmonary hypersensitivity reaction classically associated with parasitic larval migration, typically presenting with fleeting infiltrates and peripheral eosinophilia. However, atypical presentations can occur in patients with chronic infection, altered immunity, or underlying lung disease. The coexistence of multidrug-resistant tuberculosis (MDR-TB), intestinal ascariasis, and post-tuberculosis bronchiectasis is exceedingly uncommon and diagnostically challenging due to overlapping pulmonary findings. Case Presentation A 42-year-old woman with bronchial asthma and previously treated pulmonary tuberculosis complicated by bronchiectasis presented with acute respiratory failure following a two-week history of productive cough and progressive dyspnea. Endotracheal aspirate real-time PCR detected Mycobacterium tuberculosis resistant to rifampicin and isoniazid, confirming MDR-TB. Sputum microscopy showed AFB 3+. Chest radiograph revealed patchy reticulonodular infiltrates superimposed on chronic fibrotic and bronchiectatic changes, with transient opacities suggestive of a Loeffler-like reaction. Peripheral eosinophilia was absent (E 1%).During hospitalization, the patient expelled adult Ascaris lumbricoides worms orally on three consecutive days and once via the nares. Stool examination confirmed Ascaris lumbricoides ova, establishing intestinal ascariasis. She was treated with systemic corticosteroids, broad-spectrum antibiotics, mechanical ventilation, and anti-helminthic therapy, resulting in initial improvement and partial clearing of transient infiltrates. However, her course was later complicated by ventilator-associated pneumonia, and despite aggressive management, she eventually expired. Discussion This case illustrates the rare coexistence of MDR-TB, intestinal ascariasis, and TB bronchiectasis presenting as a Loeffler-like pulmonary reaction without peripheral eosinophilia. The absence of eosinophilia may reflect immune modulation from chronic infection, corticosteroid use, or impaired host response from structural lung damage. The overlapping features of MDR-TB reactivation and parasitic hypersensitivity made diagnosis difficult, emphasizing the importance of maintaining a broad differential in endemic settings. The patient’s subsequent deterioration underscores the vulnerability of those with advanced structural lung disease to secondary infections and poor outcomes. Conclusion In TB-endemic regions, parasitic co-infection should be considered in MDR-TB patients with bronchiectasis presenting with new or transient infiltrates, even without eosinophilia. Early recognition can prevent misdiagnosis and guide appropriate management. This case also highlights the high risk of complications such as ventilator-associated pneumonia and mortality in patients with advanced post-TB lung disease. This abstract is funded by: None
Tan et al. (Fri,) studied this question.