Post-Renal Transplant Miliary Mottling: Not Always Tuberculosis

A 28-year-old male, 3 years post renal transplant with stable graft function, presented with vomiting for 2 days. He had graft dysfunction and graft biopsy done revealed acute cell - mediated rejection BANFF-IA. After receiving glucocorticoids for rejection, he developed severe enterocolitis and impending respiratory failure. Chest X-ray and computed tomography of the chest revealed miliary mottling. Evaluation showed presence of filariform larvae of Strongyloides stercoralis in the stool and sputum. A diagnosis of Strongyloides Hyperinfection Syndrome (SHS) was made. After a prolonged course of treatment with noninvasive ventilation, broad-spectrum antimicrobials, parenteral ivermectin and oral albendazole therapy, he eventually recovered. This case report is to highlight that Strongyloides Hyperinfection Syndrome should also be considered in the differential in any immunocompromised patient presenting with miliary mottling in imaging.