Thanks to the Human Dx Project for providing us with this fascinating case of a middle aged woman with history of asthma who presented with acute onset of fever and epigastric abdominal pain as well as a chronic progressive cough, found to be febrile, tachycardic, and ill appearing, with E coli bacteremia of unknown source.  Further history taking revealed a similar hospitalization several months prior with idiopathic E coli bacteremia.  Strongyloides titers were sent and markedly elevated.  She was treated with ceftriaxone and ivermectin and made a full recovery.

Clinical Pearls: 

• Absence of eosinophilia does not rule out strongyloides.  Keep in mind that those presenting with severe illness and hemodynamic instability are commonly in a high cortisol state which can lead to eosinophil apoptosis.  Also, in those with history of steroid use (even for short periods of time), eosinophil count can be negative.
• Think of strongy in anyone with the right travel history, older age, malnutrition, HIV, or steroid use.
• Signs and symptoms can be quite non-specific so a high index of suspicion is required to make the diagnosis.
• Think of strongyloides in a patient with history of recurrent GNR bacteremia of unknown etiology!

Strongyloidiasis 

• Higher incidence noted going from yellow to orange to red on the map above
• Epidemiology
  • Typically in travelers to endemic areas, immigrants from endemic regions, or anyone with barefoot contact with infested soil.
  • Risk factors include older age, malnutrition, HIV, and steroid use
• Signs and symptoms
  • Infected people can be asymptomatic or minimally symptomatic for years:
    • Could also have mild waxing and waning GI, skin, or pulmonary symptoms for years
    • Eosinophilia without symptoms
  • Skin: urticarial, larvae currens (see picture below), angioedema, erythroderma
  • Pulmonary: chronic cough, hemoptysis, recurrent pneumonia, astham that gets worse with steroids
  • GI: upper abdominal pain, duodenitis, diarrhea, anorexia, recurrent enteric GNR bacteremia
  • Disseminated disease/hyperinfection syndrome:
    • Increased parasite burden due to autoinfection (see picture below)
    • Massive dissemination of larvae to lungs, liver, heart, CNS, and endocrine glands
    • Can present with septic shock or multiorgan failure

      

• Diagnosis:
  • Stool O&P: <50% sensitive and requires multiple samples due to intermittent shedding
  • Serologies: 89% sensitive
• Treatment:
  • Ivermectin or albendazole
  • Hyperinfection/disseminated disease: above PLUS broad-spectrum antibiotics

Quick review of endemic dimorphic fungi:

• Southwest US ⇒ Cocci
• Ohio & Mississippi River Valley ⇒ Histo
• Southeast/South-central US ⇒ Blasto
• Southeast Asia ⇒ Penicillium
• South America ⇒ Paracocci, histo, blasto, cocci