Strongyloides hyperinfection complicated by invasive aspergillosis and osmotic demyelination syndrome

Strongyloides stercoralis is an intestinal nematode endemic in tropical and subtropical regions, capable of persisting for decades through an auto-infective life cycle. In immuno-compromised hosts, particularly those receiving corticosteroids, accelerated auto-infection can result in a hyperinfection syndrome characterised by massive larval proliferation, dissemination and life-threatening secondary bacterial or fungal infections. We report a known alcoholic with chronic steroid exposure who presented with pulmonary and gastrointestinal manifestations of hyperinfection, with larvae detected both in sputum and stool. His course was complicated by multidrug-resistant Klebsiella pneumoniae bacteraemia, probable invasive pulmonary aspergillosis and osmotic demyelination syndrome related to severe electrolyte disturbances. He improved with ivermectin and supportive therapy, highlighting the importance of early recognition of strongyloidiasis in steroid-exposed patients in endemic regions.