Strongyloides stercoralis: From chronic silent infection to fulminant catastrophe

Strongyloidiasis can persist lifelong through autoinfection and may abruptly progress to hyperinfection with disseminated disease. We report a 38-year-old woman from southwestern Colombia with two months of postprandial bilious vomiting, oral intolerance, abdominal pain and 19 kg weight loss, initially managed as upper gastrointestinal bleeding and constitutional syndrome with suspected malignancy. Endoscopy showed hemorrhagic/atrophic gastritis, a deformed pylorus and irregular duodenal mucosa. On day 4 she deteriorated with hypoxemia and refractory shock; intubation, vasopressors, broad-spectrum antibiotics and corticosteroids were instituted, but she died due to refractory septic shock and multiorgan failure. Histopathology of duodenal biopsies revealed numerous Strongyloides stercoralis larvae. Autopsy confirmed disseminated strongyloidiasis with hyperinfection, polymicrobial pulmonary and central nervous system infection, and multiorgan failure. This case illustrates a lethal gastrointestinal presentation mimicking gastric outlet obstruction without overt immunosuppression. In endemic settings, the combination of severe malnutrition, unexplained upper gastrointestinal symptoms and characteristic duodenal mucosal changes should prompt early testing for Strongyloides to avoid corticosteroid-triggered hyperinfection. Timely diagnosis and ivermectin-based therapy are essential to prevent catastrophic outcomes.