Spontaneous
The patient was a 43-year-old Hispanic man from Peru, with a history of trips to the jungle regions of Peru and Brazil two decades ago. He was diagnosed by his primary care physician with Bell’s Palsy three weeks before being admitted and was started on prednisone 50 mg bid, which he continued to take up to three weeks without proper follow-up. He presented to the Emergency Department with a history of diarrhea, weight loss of 10 kg, and intermittent fever for the three previous weeks. Additionally, the patient presented hematochezia three days prior to admission. He had pallor, tachycardia, mild abdominal pain upon palpation, and blood on rectal examination. The rest of the physical exam was otherwise unremarkable at the Emergency Department. His complete blood count showed 16000 leukocytes/mm3 (82% neutrophils, 2% eosinophils, 7% bands, 8% lymphocytes, and 1% monocytes), hemoglobin 8 g/dL, and 700 000 platelets. The patient was suspected to have diverticulitis. He was started on intravenous Ciprofloxacin and Metronidazole, received blood transfusions, and was transferred to an Internal Medicine Service. One week after admission, the patient presented with drowsiness, bradylalia, bradypsychia, nuchal rigidity, positive Kernig and Brudzinski signs, and fever. Furthermore, he developed crackles at the right lung base, abdominal distension, and constipation. A lumbar puncture showed a cloudy and turbid fluid, protein levels 179 mg/dL, glucose 5 mg/dL, cell count 2070 leukocytes/mm3 (92% neutrophils, 2% mononuclear cells), and Gram-negative rods in the Gram stain. A new complete blood count showed 25000 leukocytes/mm3 (84% neutrophils, 0% eosinophils, 7% bands, 4% lymphocytes, and 5% monocytes). A CT scan of the abdomen revealed a dilated ascending colon (Figure
Dilatation of the ascending colon and diffuse thickening of the walls of the transverse colon, which shows partial stenosis and inflammatory changes in the adjacent mesocolon.
He was started on Ceftriaxone and Vancomycin as empiric therapy for meningitis. The CSF culture was positive for extended spectrum
(a) Filariform larvae of
Spontaneous
Common predisposing factors for Gram-negative bacillary meningitis include chronic alcoholism, liver cirrhosis, neoplasia, diabetes mellitus, corticosteroids or other immunosuppressive drugs, HIV infection, and, rarely, systemic infestations with SS [
In the present case, the fact that the patient’s gastrointestinal disturbances concur with the usage of systemic corticosteroids was underestimated. Since he did not have any other known risk factors, the unusual meningitis was attributed to the corticosteroids use, and the possibility of being related to a parasite infection was not considered.
Most cases of SS infection are asymptomatic or present with mild nonspecific gastrointestinal disturbances. However, hyperinfection syndrome, which occurs due to disruption of the intestinal wall by the parasite and its dissemination through the body, can actually be life-threatening [
It is common among patients who develop hyperinfection syndrome the recent usage of corticosteroids and other immunosuppressive drugs, as well as the presence of other comorbidities like HTLV-1 or HIV infection, alcoholism, and diabetes [
Unlike other nematodes, SS is capable of reinfecting the host without the need of an external cycle. This mechanism, known as autoinfection, allows the parasite to persist even for decades in the host [
The autoinfection cycle of SS allows it to cause both parasitic and enteric bacterial infections at distant locations in the body, causing localized infections and sepsis by translocation on the nematode surface [
Eosinophilia is usually not seen in HS, as in our patient, but in his situation the use of corticosteroids probably also contributed to this fact [
Different studies report that patients with symptomatic strongyloidiasis have a high frequency of invasive infections by enteric bacteria and
Due to the patient epidemiological history and gastrointestinal manifestations, such as weight loss, diarrhea, hematochezia, and ileum, SS infection should have been considered in the differential diagnosis. Clinicians should have a high level of clinical suspicion for the diagnosis of strongyloidiasis in patients with severe extraintestinal infections by enteric organisms without a clear underlying predisposing factor [
Written informed consent was obtained from the patient’s widow for publication of this case report and accompanying images.
The authors declare that they have no conflict of interests.