A49-23 Caught in the Dark

Abstract Introduction While the prevalence of strongyloidiasis may be as high as 600 million cases and is endemic in many countries, infection in the United States is less common. Strongyloides hyperinfection syndrome/disseminated infection may occur in chronic carriers who subsequently become immune suppressed leading to accelerated autoinfection with high mortality rates. Diagnostic tools include serologic testing and microscopic examination for larvae from stool and respiratory specimens. Macroscopic “tracks” may also be incidentally observed from routine culture plates due to displacement of bacterial colonies by live larvae. Case A 68-year-old woman with microscopic polyangiitis recently treated with rituximab and high dose pulse corticosteroids presented with acute respiratory distress syndrome and septic shock. She developed multiorgan failure despite being treated with broad-spectrum antimicrobials. She underwent a bronchoalveolar lavage (BAL) consistent with diffuse alveolar hemorrhage (DAH). BAL was also submitted for bacterial, fungal, and Legionella culture. After 2 days incubation the laboratory observed a bacterial growth pattern suggestive of Strongyloides movement on the buffered charcoal yeast agar plates. A subsequent ova and parasite exam on the BAL sample confirmed the presence of Strongyloides stercoralis filariform and rhabditiform larvae. She was treated with enteral ivermectin and albendazole and subcutaneous ivermectin was obtained after appropriate FDA clearance from a local veterinarian supply store. She was also treated for multiple infections, including polymicrobial Gram-negative pneumonia, E. coli and Enterobacter bacteremia, candidemia, invasive pulmonary aspergillosis, and CMV pneumonitis, and unfortunately died despite aggressive care. Despite living in the United States for most of her adult life, the patient was from an endemic country. It is likely that treatment for vasculitis caused a Strongyloides hyperinfection syndrome/disseminated disease. The accelerated autoinfection cycle led to her polymicrobial bacteremia and pneumonia, organ failure and death. Discussion This case highlights the importance of maintaining a high clinical suspicion for Strongyloides hyperinfection syndrome and disseminated disease, especially in patients who are immune suppressed and presenting with Gram-negative bacteremia. Many society guidelines recommend empiric treatment prior to immune suppression in patients from endemic countries, which could have impacted this patient’s outcome. Although patients with strongyloidiasis often have peripheral eosinophilia, those with strongyloides hyperinfection syndrome usually have normal or low eosinophil counts, likely due to steroid use. Visible tracks on culture plates can alert clinical laboratories to the presence of Strongyloides larvae in patient specimens. In patients with poor enteric absorption, subcutaneous ivermectin may be obtained from non-traditional sources with FDA and IRB concurrence. This abstract is funded by: none