Pulmonary strongyloidiasis associated CD3+ large granular lymphocytosis

We report a case of pulmonary strongyloidiasis in a patient with large granular lymphocytosis. He was on short-term high dose immunosuppressant therapy. A 77-year-old white male presented to the emergency room with fever and shortness of breath for 10 days. The patient had been diagnosed about 3 months prior to this presentation with "large granular lymphocytosis" (LGL) after a workup for pancytopenia. Methotrexate and prednisone had been started 1 month ago for the treatment of LGL. Five days prior to the current presentation, he had been started on moxifloxacin as an outpatient but got progressively worse and came to an emergency room. Bronchial washings (bronchoalveolar lavage) demonstrated numerous filariform larvae of Strongyloides stercoralis. The patient was treated with ivermectin and improved. Pulmonary strongyloidiasis should be considered in the differential if X-ray findings show a interstitial or alveolar pattern and if the patient has visited the endemic areas, even in the remote past.