Fatal strongyloidiasis after corticosteroid therapy for presumed chronic obstructive pulmonary disease.

INTRODUCTION: Strongyloidiasis is a neglected tropical disease with global prevalence. Under some cases of immune suppression (especially with corticosteroid administration), the nematode involved disseminates, leading to an amplified, possibly lethal hyper-infection syndrome. CASE PRESENTATION: A 56-year-old Nepalese man presenting with chief complaints of nausea, vomiting, joint pain and abdominal cramps was admitted to Sumeru Hospital. His past history revealed: chronic obstructive pulmonary disease (COPD), systemic hypertension and previously treated pulmonary tuberculosis. The patient had been treated with oral prednisolone (60 mg gl-1) for 8 days due to a presumed exacerbation of his COPD. Sequentially, he developed haemoptysis, chest tightness, frequent wheezing and worsening cough. Bronchoscopy showed severe diffuse alveolar haemorrhage; microbiological examination of broncho-alveolar lavage (BAL) was recommended. Examination of an acid fast bacilli stain preparation of BAL revealed filariform larvae of Strongyloides. Stool specimen examination revealed larvae of Strongyloides. The physical condition of the patient began to deteriorate; a few days after admission, vancomycin-sensitive Enterococcus faecium was isolated from a blood sample. He was treated with ivermectin and albendazole for strongyloides and linezolid plus vancomycin for E. faecium. However, the patient failed to recover from the illness and died. CONCLUSION: The findings of our study suggest that corticosteroid administration in strongyloidiasis can lead to the development of fatal strongyloides hyper-infection syndrome. Hence our experience suggests the need for early diagnosis of strongyloidiasis to avoid such an outcome. A deterioration of the patient's condition after the initiation of corticosteroid therapy in endemic areas should raise the possibility of strongyloidiasis.

Disseminated Nocardiosis in renal transplant recipient under therapy for pulmonary tuberculosis: a case report.

BACKGROUND: Nocardiosis is an opportunistic infection in a patient with underlying immune suppression and organ transplant. Clinical syndromes are varied and ranges from pulmonary, disseminated, cutaneous along with central nervous system involvement. CASE PRESENTATION: Herein, we report a rare case of disseminated pulmonary nocardiosis with cerebral manifestation in a 66 year-old-Nepali farmer; with a history of renal transplantation and undergoing therapy for pulmonary tuberculosis. Radiographic imaging revealed multiple opacities of varying sizes in bilateral lung field mediastinal, retroperitoneal lymphadenopathy, and ill-defined lesion with surrounding edema seen in left occipitoparietal region of brain. Bacteriological assessments of bronchoalveolar lavage and purulent fluid extracted intra-operatively from the lesion confirmed the case as Nocardiosis. CONCLUSION: Disseminated Pulmonary nocardiosis with central nervous system involvement carries a poor prognosis. However, early diagnosis of the case, the administration of appropriate antibiotic, stereotactic aspiration alone or craniotomy has a successful outcomes even in a post renal transplant patient treated with anti tuberculosis treatment.