Strongyloides stercoralis hyperinfection presenting with symptoms mimicking acute exacerbation of chronic obstructive...

Hyperinfection syndrome with Strongyloides stercoralis is not uncommon in immunocompromised patients. We present 2 fatal cases of Strongyloides hyperinfection with initial presentation mimicking acute exacerbation of chronic obstructive pulmonary disease (COPD). Both cases had a history of COPD and had received systemic steroid treatment before or during admission. The initial chest radiograph in both of these cases showed diffuse axial interstitial pattern. The sputum examinations of Gram stain both yielded larvae of Strongyloides stercoralis precipitously. Case 1 developed acute respiratory distress syndrome and bacteremia of Escherichia coli and Klebsiella pneumoniae soon after admission, and died even after receiving albendazole and antibiotic treatment. Case 2 received albendazole and antibiotic treatment for over 2 weeks, but developed refractory aseptic meningitis and died of septic shock. Neither case had high eosinophil count in peripheral blood during admission. Clinical manifestations of unexplained wheezing and respiratory failure, increased infiltration on chest radiograph, Gram-negative bacteremia, and aseptic meningitis may all be clues of Strongyloides hyperinfection. Due to the high mortality rate and severe complications in these patients, clinicians should always keep this diagnosis in mind, especially when dealing with immunocompromised patients. We suggest that a screening test be done for patients who live in endemic areas and those who are going to receive steroids for chronic disease.