%0 Journal Article
%T Strongyloides stercoralis and Organ Transplantation
%A Bhalaghuru Chokkalingam Mani
%A Moses Mathur
%A Heather Clauss
%A Rene Alvarez
%A Eman Hamad
%A Yoshiya Toyoda
%A Mark Birkenbach
%A Mustafa Ahmed
%J Case Reports in Transplantation
%D 2013
%I Hindawi Publishing Corporation
%R 10.1155/2013/549038
%X Strongyloides is a parasite that is common in tropical regions. Infection in the immunocompetent host is usually associated with mild gastrointestinal symptoms. However, in immunosuppressed individuals it has been known to cause a ¡°hyperinfection syndrome¡± with fatal complications. Reactivation of latent infection and rarely transmission from donor organs in transplanted patients have been suggested as possible causes. Our case highlights the importance suspecting Strongyloides in transplant recipients with atypical presentations and demonstrates an incidence of donor derived infection. We also review the challenges associated with making this diagnosis. 1. Case A 60-year-old Hispanic male originally from Puerto Rico with end-stage ischemic cardiomyopathy status postorthotopic heart transplantation (OHT) in July 2012 presented 2 months after transplant with fatigue and malaise. On arrival he appeared ill but afebrile. He had an episode of hemoptysis and was admitted for further evaluation. His posttransplant course was complicated by recurrent episodes of cellular rejection requiring both oral and intravenous pulse dose steroids. His immunosuppression regimen at time of presentation included mycophenolate mofetil 1500£¿mg twice daily in addition to tacrolimus 2.5£¿mg and 20£¿mg prednisolone daily. His most recent endomyocardial biopsy (EMBx) revealed resolution of cellular rejection with normal hemodynamics. On hospital day 1, he underwent repeated EMBx which was negative for evidence of cellular and antibody-mediated rejection. Echocardiography and right heart catheterization revealed normal allograft function and hemodynamics. He subsequently developed a worsening respiratory distress requiring transfer to the cardiac intensive care unit and intubation. Thereafter, he became profoundly hypotensive requiring initiation of norepinephrine in addition to broad spectrum antimicrobial coverage. Over the next 72 hours, he became increasingly unstable requiring additional vasopressor support. Shortly after intubation, he underwent bronchoscopy and on day 4 of admission, bronchoalveolar lavage (BAL) revealed Strongyloides stercoralis as the parasite was visualized (Figure 1). Ivermectin and albendazole were initiated via nasogastric tube. Figure 1: BAL specimen showing adult worm. With these interventions, the patient¡¯s hemodynamic and respiratory status improved. However, his neurological status did not improve despite withdrawal of sedation. Therefore a lumbar puncture was performed which revealed vancomycin resistant enterococcus and Strongyloides in the
%U http://www.hindawi.com/journals/crit/2013/549038/