Infection with human T-lymphotropic virus type 1 (HTLV-1), endemic in Brazil, affects about 800,000 people and compromises cellular immunity, especially the Th2 response, predisposing to severe parasitic infections such as strongyloidiasis. This disease, caused by the helminth Strongyloides stercoralis, is usually asymptomatic and chronic, but in immunosuppressed individuals, such as those infected with HTLV-1, it can progress to disseminated and potentially fatal forms. We report the case of a 37-year-old man, previously bedbound due to lower-limb paraparesis without an etiologic diagnosis, who developed an acute overlapping condition with headache, fever, confusion, and left hemiparesis. During the investigation for encephalitis, he developed severe abdominal distension and pain, with cessation of stool and flatus passage, progressing to massive hematemesis. Upper gastrointestinal endoscopy revealed thick erosions in the esophagus and stomach and a giant duodenal ulcer with stenosis. The course progressed with hemodynamic deterioration and worsening signs of acute abdomen, requiring exploratory laparotomy and two surgical approaches. HTLV-1 serology was positive during the investigation, and pathological examination of samples revealed S. stercoralis eggs in esophageal, gastric, and duodenal tissues. Despite antiparasitic treatment and intensive support, the patient progressed to septic shock and subsequently died. The patient presented a chronic neurological condition compatible with HTLV-associated myelopathy, which involves progressive spastic paraparesis of the lower limbs, as well as urinary, sensory, and autonomic disturbances. The gastrointestinal manifestations are compatible with strongyloidiasis, which may feature abdominal pain, diarrhea, vomiting, paralytic ileus, and gastrointestinal bleeding. Bacteremia due to bacterial translocation can occur, culminating in sepsis, with evidence of mortality between 43% and 71%, particularly in immunosuppressed patients, as in this case, which demonstrates the severity of coinfection with superinfection, septic shock, and low therapeutic response. Both are neglected diseases, and the high frequency of S. stercoralis in HTLV-1 carriers reinforces the need for screening and early treatment of the parasitosis in individuals infected with the retrovirus, in order to prevent severe complications and fatal outcomes.
Miranda et al. (Sun,) studied this question.