Immune reconstitution syndrome to Strongyloides stercoralis infection

We thank McCarthy and Currie for their response [1] to our case report [2], which described a young Eritrean man with HIV and hepatitis B infections who presented with an inflammatory colitis, 6 weeks after starting antiretroviral therapy and had Strongyloides larvae detected in stool samples. After treatment with ivermectin, his symptoms, and the associated intestinal dilatation, resolved. His presentation was localized to the intestines and comprised loss of appetite, abdominal pain, vomiting and weight loss. There were no respiratory symptoms and no evidence of dissemination of Strongyloides larvae or bacterial sepsis. We have seen and recognized the well established, strong association of corticosteroid treatment with Strongyloides hyperinfection syndrome [3–5] and agree that excluding Strongyloides infection is important when considering steroid treatment in individuals who have lived in an endemic area [1]. We also concur that immune suppression due to HIV infection itself does not appear to cause hyperinfection [6]. In this case, however, although this patient had received steroid treatment (for thrombocytopaenia) in the weeks preceding presentation, there was no evidence of dissemination of the parasite outside the gastrointestinal system, and therefore a local inflammatory response, coinciding with rapid immunological recovery due to antiretroviral treatment, fits much better with the clinical picture. We, therefore, proposed that this case comprises immune reconstitution syndrome and not disseminated infection secondary to corticosteroid therapy. Acknowledgement There is no conflict of interests.