Introduction: Strongyloides sterocolitis, a soil-transmitted, gut-inhabiting parasite, is estimated to infect 613 million individuals worldwide. It is globally endemic, with its prevalence among subtropical/tropical climates reported as high as 40%. Disease manifestation can range from asymptomatic chronic infection to life-threatening complications such as hyperinfection syndrome and disseminated disease. Hyperinfection is associated with severe complications and mortality.
Description: A 65-year-old female with no known medical history presented with generalized weakness, diarrhea, and abdominal pain and was admitted to the intensive care unit for septic shock. Social history was significant for recent emigration from Thailand one month prior. Blood cultures on admission were positive for pansensitive Klebsiella pneumoniae. CT imaging revealed hepatic and psoas abscesses, both culture-positive for the same species of Klebsiella. Abscesses underwent drainage, and the patient was treated with a course of IV ceftriaxone. The patient clinically improved and was downgraded from the ICU. Despite an antibiotic course and presumed source control, the patient returned to the ICU with recurrent septic shock; blood cultures were once again positive for Klebsiella pneumoniae. A new right-sided empyema, Klebsiella pneumoniae positive, and a new liver abscess, Enterococcus faecium positive, were identified. Throughout admission, serial differentials demonstrated increasing absolute eosinophil count. Given worsening eosinophilia, initial GI symptoms on presentation, and endemic exposure, stool ova was ordered, revealing Strongyloides sterocolitis infection. She received ivermectin treatment for presumed Strongyloides hyperinfection syndrome. Treatment of the Strongyloides resulted in the resolution of recurrent bacterial infection and improved eosinophilia.
Discussion: Strongyloides hyperinfection represents accelerated chronic autoinfection with increased larvae burden and GI mucosal disruption. As larvae migrate to the bloodstream, enteric pathogens translocate, leading to bacteremia and other infectious complications. In patients presenting with bacteremia secondary to enteric bacteria, eosinophilia, and epidemiological exposure, clinicians should have a high suspicion for Strongyloidiasis.
