A CASE OF DISSEMINATED STRONGYLOIDIASIS DURING TREATMENT FOR COVID-19

ABSTRACT

TOPIC Chest Infections TYPE Fellow Case Reports INTRODUCTION: Strongyloides stercoralis is a parasitic infection that is endemic in subtropical and tropical climates. Due to the unique life cycle of this parasite, many hosts are asymptomatic. If a host becomes immunosuppressed, a hyperinfection syndrome caused by proliferation of these nematodes can ensue (1). CASE PRESENTATION A 72-year-old Nicaraguan male was admitted to the hospital with dyspnea. A nasopharyngeal swab confirmed SARS-COV2 infection. He was admitted to the medical floor but was transferred to the intensive care unit due to worsening hypoxia. He was subsequently intubated and treated with intravenous dexamethasone and full dose anticoagulation. His course was complicated by acute respiratory distress syndrome ultimately necessitating tracheostomy, multi-drug resistant Escherichia coli pneumonia, prolonged shock requiring continuous vasopressor support and stress dose steroids, diarrhea, and persistent fevers despite broad antimicrobial coverage. His peripheral eosinophil count was noted to be elevated. This in combination with his Nicaraguan origin prompted a stool ova and parasite examination to evaluate for helminthic infection. Microscopic evaluation revealed rhabditiform larvae consistent with Strongyloides stercoralis. Review of a bronchoalveolar lavage gram stain demonstrated a larvae-like structure suspicious for Strongyloides stercoralis as well. He was diagnosed with disseminated strongyloidiasis and treated with ivermectin. His fevers and vasopressor requirements subsequently resolved. DISCUSSION: High dose glucocorticoid therapy has a known immunosuppressive effect on a host's response to infectious agents. In this case, the use of steroids for COVID-19 and shock resulted in strongyloides hyperinfection syndrome. The presence of an Escherichia coli pneumonia was, in retrospect, an important clue to the patient's presentation. Bacterial pneumonia from enteric organisms has been found to be a common co-infection in patients with pulmonary strongyloidiasis (2). Bacteria are transmitted from the intestine, where the larvae start their life cycle. They move into the bloodstream via penetration of the intestinal mucosa by the larvae. The larvae then carry the bacteria into the lungs by burrowing into the alveoli (2). Strongyloides is estimated to infect millions of people worldwide and thus there appears to be an increased risk for associated hyperinfection in the setting of steroid utilization for COVID-19 infections (3). It is important for clinicians to be aware of this risk and to delineate strategies for appropriate testing and initiation of treatment. CONCLUSIONS: Disseminated strongyloidiasis can be detrimental in patients with COVID-19. In the setting of a global pandemic during which one of the mainstays of treatment is high dose glucocorticoids, it is important to be cognizant of dormant infections like Strongyloides that may become unmasked during treatment. REFERENCE #1 Nutman TB. Human infection with Strongyloides stercoralis and other related Strongyloides species. Parasitology. 2017 Mar;144(3)263-273. REFERENCE #2 Nabeya, D., Haranaga, S., Parrott, G.L. et al. Pulmonary strongyloidiasis assessment between manifestation and radiological findings in 16 severe strongyloidiasis cases. BMC Infect Dis 17, 320 (2017). REFERENCE #3 Stauffer WM, Alpern JD, Walker PF. COVID-19 and Dexamethasone A Potential Strategy to Avoid Steroid-Related Strongyloides Hyperinfection. JAMA. 2020;324(7)623–624. DISCLOSURES No relevant relationships by William Bender, source=Web Response No relevant relationships by Eliana Gonzalez, source=Web Response No relevant relationships by Anjali Patel, source=Web Response No relevant relationships by Margaret Williamson, source=Web Response