Disseminated Strongyloiodes Infection after Corticosteroid Use

ABSTRACT

INTRODUCTION: While there are endemic foci of Strongyloides in the southeastern United States, strongyloidiasis in the US is most commonly found in immigrants and military veterans who have lived in endemic regions. We report a case of reactivated disseminated strongyloidiasis in a critically ill COVID-19 patient. DESCRIPTION A 46 year old undomiciled man with a medical history of hypertension was found down by a friend and brought to the hospital for evaluation of altered mental status. The patient immigrated from Mexico in 1991 and lived in Florida for several years working as a gardener. On presentation he complained of headaches, with tremors and tongue fasciculations noted on physical exam. He underwent treatment for alcohol withdrawal. His hospital course was complicated by COVID-19 pneumonia requiring intubation, and a subarachnoid hemorrhage that did not require acute neurosurgical intervention. Several days after completion of remdesivir and dexamethasone treatment for COVID-19, the patient's absolute eosinophil count increased from 20/ uL on admission to 340/uL with a peak at 1500/uL. The patient was found to have Strongyloides and ESBL Klebsiella in a bronchoalveolar lavage after a bedside bronchoscopy. Ivermectin 200ug/kg/day and meropenem 2g every 8 hours were started. The patient remained persistently comatose despite being off sedation and a relatively benign brain MRI that demonstrated resolving subarachnoid hemorrhages. Strongyloides were confirmed in the CSF nine days after initial discovery in the BAL. Albendazole 400mg BID was added to the regimen and meropenem was continued for possible culture negative bacterial meningitis in the setting of disseminated strongyloidiasis. HIV and HTLV-1 serology was negative. The patient remained in the ICU with poor neurological status and ongoing goals of care discussions with the family. DISCUSSION: Strongyloides hyperinfection is an uncommon complication with a high mortality rate, with meningeal involvement often described post-mortem. Prophylactic anti-parasitic agents can be considered for patients identified as high risk for chronic strongyloidiasis who are about to undergo corticosteroid treatments, including COVID-19 associated regimens.