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
References
[1]
A. A. Siddiqui and S. L. Berk, “Diagnosis of Strongyloides stercoralis infection,” Clinical Infectious Diseases, vol. 33, no. 7, pp. 1040–1047, 2001.
[2]
M. Montesa, C. Sawhney, and N. Barrosa, “Strongyloides stercoralis: there but not seen,” Current Opinion in Infectious Diseases, vol. 23, no. 5, pp. 500–504, 2010.
[3]
B. Wong, “Parasitic diseases in immunocompromised hosts,” The American Journal of Medicine, vol. 76, no. 3, pp. 479–486, 1984.
[4]
R. Mejia and T. B. Nutman, “Screening, prevention, and treatment for hyperinfection syndrome and disseminated infections caused by Strongyloides stercoralis,” Current Opinion in Infectious Diseases, vol. 25, no. 4, pp. 458–463, 2012.
[5]
R. M. Genta, “Strongyloides stercoralis: immunobiological considerations on an unusual worm,” Parasitology Today, vol. 2, no. 9, pp. 241–246, 1986.
[6]
M. Kassalik and M. M？nkemüller, “Strongyloides stercoralis hyperinfection syndrome and disseminated disease,” Gastroenterology & Hepatology, vol. 7, no. 11, pp. 766–768, 2011.
[7]
L. A. Marcos, A. Terashima, M. Canales, and E. Gotuzzo, “Update on strongyloidiasis in the immunocompromised host,” Current Infectious Disease Reports, vol. 13, no. 1, pp. 35–46, 2011.
[8]
A. C. Roxby, G. S. Gottlieb, and A. P. Limaye, “Strongyloidiasis in transplant patients,” Clinical Infectious Diseases, vol. 49, no. 9, pp. 1411–1423, 2009.
[9]
M. W. Schaeffer, J. F. Buell, M. Gupta, G. D. Conway, S. A. Akhter, and L. E. Wagoner, “Strongyloides hyperinfection syndrome after heart transplantation: case report and review of the literature,” The Journal of Heart and Lung Transplantation, vol. 23, no. 7, pp. 905–911, 2004.
[10]
H. Z. El Masry and J. O'Donnell, “Fatal stongyloides hyperinfection in heart transplantation,” The Journal of Heart and Lung Transplantation, vol. 24, no. 11, pp. 1980–1983, 2005.
[11]
S. Mizuno, T. Iida, I. Zendejas et al., “Strongyloides hyperinfection syndrome following simultaneous heart and kidney transplantation,” Transplant International, vol. 22, no. 2, pp. 251–253, 2009.
[12]
J. Brügemann, G. A. Kampinga, A. Riezebos-Brilman et al., “Two donor-related infections in a heart transplant recipient: one common, the other a tropical surprise,” The Journal of Heart and Lung Transplantation, vol. 29, no. 12, pp. 1433–1437, 2010.
[13]
I. S. Grover, R. Davila, C. Subramony, and S. R. Daram, “Strongyloides infection in a cardiac transplant recipient: making a case for pretransplantation screening and treatment,” Gastroenterology & Hepatology, vol. 7, no. 11, pp. 763–766, 2011.
[14]
T. Said, M. R. N. Nampoory, M. P. Nair et al., “Hyperinfection strongyloidiasis: an anticipated outbreak in kidney transplant recipients in Kuwait,” Transplantation Proceedings, vol. 39, no. 4, pp. 1014–1015, 2007.
[15]
J. M. Huston, S. R. Eachempati, J. R. Rodney et al., “Treatment of Strongyloides stercoralis hyperinfection-associated septic shock and acute respiratory distress syndrome with drotrecogin alfa (activated) in a renal transplant recipient,” Transplant Infectious Disease, vol. 11, no. 3, pp. 277–280, 2009.
[16]
W. E. Hoy, N. J. Roberts Jr., and M. F. Bryson, “Transmission of strongyloidiasis by kidney transplant? Disseminated strongyloidiasis in both recipients of kidney allografts from a single cadaver donor,” Journal of the American Medical Association, vol. 246, no. 17, pp. 1937–1939, 1981.
[17]
G. Patel, A. Arvelakis, B. V. Sauter, G. E. Gondolesi, D. Caplivski, and S. Huprikar, “Strongyloides hyperinfection syndrome after intestinal transplantation,” Transplant Infectious Disease, vol. 10, no. 2, pp. 137–141, 2008.
[18]
R. Ben-Youssef, P. Baron, F. Edson, R. Raghavan, and O. Okechukwu, “Stronglyoides stercoralis infection from pancreas allograft: case report,” Transplantation, vol. 80, no. 7, pp. 997–998, 2005.
[19]
M. J. Rodriguez-Hernandez, M. Ruiz-Perez-Pipaon, E. Ca？as, C. Bernal, and F. Gavilan, “Strongyloides stercoralis hyperinfection transmitted by liver allograft in a transplant recipient: case report,” American Journal of Transplantation, vol. 9, no. 11, pp. 2637–2640, 2009.
[20]
V. Khieu, F. Sch？r, H. Marti et al., “Diagnosis, treatment and risk factors of Strongyloides stercoralis in schoolchildren in Cambodia,” PLOS Neglected Tropical Diseases, vol. 7, no. 2, Article ID e2035, 2013.
[21]
R. Ramanathan, P. D. Burbelo, S. Groot, M. J. Iadarola, F. A. Neva, and T. B. Nutman, “A luciferase immunoprecipitation systems assay enhances the sensitivity and specificity of diagnosis of Strongyloides stercoralis infection,” Journal of Infectious Diseases, vol. 198, no. 3, pp. 444–451, 2008.
[22]
J. Inês Ede, J. N. Souza, R. C. Santos et al., “Efficacy of parasitological methods for the diagnosis of Strongyloides stercoralis and hookworm in faecal specimens,” Acta Tropica, vol. 120, no. 3, pp. 206–210, 2011.
[23]
J. J. Verweij, M. Canales, K. Polman et al., “Molecular diagnosis of Strongyloides stercoralis in faecal samples using real-time PCR,” Transactions of the Royal Society of Tropical Medicine and Hygiene, vol. 103, no. 4, pp. 342–346, 2009.
[24]
H. Moghaddassani, H. Mirhendi, M. Hosseini, M. B. Rokni, G. Mowlavi, and E. Kia, “Molecular diagnosis of Strongyloides stercoralis infection by PCR detection of specific DNA in human stool samples,” Iranian Journal of Parasitology, vol. 6, no. 2, pp. 23–30, 2011.
[25]
Y. Suputtamongkol, N. Premasathian, K. Bhumimuang et al., “Efficacy and safety of single and double doses of ivermectin versus 7-day high dose albendazole for chronic strongyloidiasis,” PLOS Neglected Tropical Diseases, vol. 5, no. 5, Article ID e1044, 2011.
[26]
M. R. Costanzo, A. Dipchand, R. Starling, et al., The international society of heart and lung transplantation guidelines for the care of heart transplant recipients, Task Force 1: Peri-operative Care of the Heart Transplant Recipient, August 2010.
[27]
M. R. Mehra, J. Kobashigawa, R. Starling et al., “Listing criteria for heart transplantation: international society for heart and lung transplantation guidelines for the care of cardiac transplant candidates,” The Journal of Heart and Lung Transplantation, vol. 25, no. 9, pp. 1024–1042, 2006.
[28]
M. A. Fitzpatrick, J. C. Caicedo, V. Stosor, and M. G. Ison, “Expanded infectious diseases screening program for Hispanic transplant candidates,” Transplant Infectious Disease, vol. 12, no. 4, pp. 336–341, 2010.
