lmo Laboratory Medicine Online Lab Med Online ∗∗ 2093-6338 The Korean Society for Laboratory Medicine 10.3343/lmo.2019.9.3.171 lmo-9-171 Original Article A Case of Chronic Strongyloidiasis with Recurrent Hyperinfection ParkKuenyoulM.D. 1 KimMin-SunM.D. 1 ChangJeonghyunM.D. 1 KimEo JinM.D. 2 YooChanghoonM.D. 3 KimMin JaeM.D. 4 SungHeungsupM.D. 1 KimMi-NaM.D. 1 Department of Laboratory Medicine, College of Medicine and Asan Medical Center, Seoul, Korea Department of Internal Medicine, College of Medicine and Asan Medical Center, Seoul, Korea Department of Oncology, College of Medicine and Asan Medical Center, Seoul, Korea Department of Infectious Diseases, University of Ulsan, College of Medicine and Asan Medical Center, Seoul, Korea Corresponding author: Mi-Na Kim, M.D., Ph.D. https://orcid.org/0000-0002-4624-6925 Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: +82-2-3010-4511, Fax: +82-2-478-0884, E-mail: mnkim@amc.seoul.kr 07 2019 20 07 2019 9 3 171 176 Copyright © 2019 The Korean Society for Laboratory Medicine 2019 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract

Strongyloides stercoralis is an intestinal nematode that often causes chronic diarrhea and may develop severe complicated form of hyperinfection or disseminated infection in immunocompromised patients. Here, we report a case of recurrent strongyloidiasis presenting with pulmonary and meningeal involvement. A 55-year-old male diagnosed with pancreatic cancer 4 months ago was admitted due to chronic diarrhea, abdominal pain, and weight loss for 2–3 months. He had been treated with albendazole for chronic recurrent strongyloidiasis 13 years ago and again 2 years ago. He developed sepsis of Klebsiella pneumoniae and Escherichia coli on Days 3 and 7, respectively, and then meningitis of E. coli on Day 42. Strongyloidiasis was diagnosed by detection of abundant filariform larvae in sputum specimens on Day 15. He was treated for disseminated strongyloidiasis with albendazole and ivermectin for five weeks until clearance of larvae was confirmed in sputum and stool specimens. Laboratory diagnosis is important to guide appropriate treatment and to prevent chronic and recurrent strongyloidiasis.

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Microscopy of sputum and stool specimens showing Strongyloides stercoralis larvae. (A) coiled larvae (arrowheads) of spiral shape in endotracheal aspirates (gram stain, ×100) (B) filariform stage which has long esophagus, and notched tail end in endotracheal aspirates (formalin-fixed, ×400) (C) rhabditiform stage which has short buccal cavity in stool (formalin-fixed, ×400).

Clinical and laboratory findings of the present case, including bowel habit, antihelminth treatment, parasitic examination of sputum and stool specimens, leukocyte count of peripheral blood, and bacterial cultures of blood and cerebrospinal fluid. D, denoted diarrhea; 0, Not observed; 1, 1–2/cover glass; 2, 3–9/cover glass; 3, ≥10/cover glass as a quantitation of larvae per 22 mm cover glass of wet mount in sputum and stool specimens; ○, No growth from blood culture; ●, Klebsiella pneumoniae from blood culture; ▲, Escherichia coli from blood culture; ■, Escherichia coli from cerebrospinal fluid culture.

Case presentation of hyperinfective strongyloidiasis in Korea, 2010–2018

No. Age/ sex Year of report Underlying disease Immunosuppression Primary sample identified Bacteremia Meningitis Therapy Prognosis
1 65/M 2010 [15] Lung cancer Corticosteroid Sputum + (Enterobacter cloacae) – Albendazole 800 mg/day, 6 days Improved
2 73/F 2012 [16] Heart Disease Corticosteroid Bronchoalveolar lavage + (Enterococcus faecium) Present Albendazole 400 mg/day, 6 days Deceased
3 71/M 2014 [17] Gastric Cancer No Gastric tissue – – Ivermectin 15 mg/day, 2 days Improved
4 55/M Present case Pancreatic cancer No Bronchoalveolar lavage + (Escherichia coli, Klebsiella pneumoniae) Present Albendazole 400 mg/day+ Ivermectin 12 mg/day, ≥4 weeks Not improved