Disseminated Strongyloides stercoralis infection in the setting of Escherichia coli meningitis and bacteraemia in a patient living with HIV on high-dose corticosteroid therapy.

Strongyloidiasis, a helminth infection caused by Strongyloides stercoralis, can be complicated by hyperinfection, especially in the setting of immunosuppression; however, many patients go undiagnosed. One clue to diagnosis is unexplained gram-negative bacteraemia or meningitis in patients who are immunosuppressed. Serology can be helpful but may be negative in these patients who are immunocompromised.We present the case of a white cisgender man from Central America in his 40s, living with HIV, with a CD4 count of 77 cells/µL. He was diagnosed with Strongyloides hyperinfection after an increase in his steroid dose. He also had Escherichia coli meningitis and bacteraemia. Strongyloidiasis was diagnosed by stool microscopy despite a negative serology test.This case highlights the challenges in diagnosing strongyloidiasis in the setting of immunosuppression. A high index of clinical suspicion is warranted for patients living with HIV on high-dose corticosteroids. Up to three stool microscopy studies for Strongyloides should be sent in addition to serology.

Immune Reconstitution Inflammatory Syndrome with Recurrent Paradoxical Cerebellar HIV-Associated Progressive Multifocal Leukoencephalopathy.

Progressive multifocal leukoencephalopathy (PML), presenting as immune reconstitution inflammatory syndrome (IRIS), is a known complication of antiretroviral therapy (ART) in people living with HIV (PLWH). Typically preceded by ART initiation, IRIS may appear simultaneously/unmasked (PML-s-IRIS) or as a delayed/worsening/paradoxical (PML-d-IRIS) presentation of known PML disease. Primary cerebellar tropism continues to be a rare presentation, and paradoxical cerebellar involvement of PML-IRIS syndrome can be a challenge for both diagnosis and management. Steroids have been suggested as a possible therapy in severe cases but the duration of steroid therapy remain elusive. Our case is that of a 34-year-old man with newly diagnosed HIV simultaneously found to have cerebellar PML. His PML lesions however worsened after initiation of ART (PML-d-IRIS) with evidence of increased intracranial pressure. Despite initial favorable response to a short duration of steroids, he had multiple recurrence of his PML lesions after steroids were discontinued. The presence of predominant cerebellar lesions and the question of how long steroids should be provided to prevent or minimize PML recurrence is the highlight of our case. This report emphasizes the need for more controlled studies to assist clinicians in the optimal diagnosis and management of PML-IRIS in PLWH.