Hidden risk: Corticosteroid exposure and severe outcomes in patients with latent Strongyloides stercoralis

Strongyloides stercoralis is a soil-transmitted helminth capable of lifelong persistence through autoinfection, placing individuals with latent infection at risk during immunosuppression. Although corticosteroids are recognized triggers for hyperinfection and dissemination, population-level data quantifying these risks remain limited. We conducted a multicentre retrospective cohort study using the TriNetX Global Collaborative Network. Adults with laboratory-confirmed latent Strongyloides infection (positive IgG serology) were included, while patients with active disease were excluded. Corticosteroid exposure was defined as receipt within 30 days of the index test. Propensity score matching compared outcomes between patients with latent infection who did and did not receive corticosteroids. Secondary analyses compared steroid-exposed patients with and without Strongyloides and evaluated prophylactic ivermectin among steroid-exposed seropositive patients. The primary outcome was 90-day mortality; secondary outcomes included sepsis, bacteraemia, and ICU admission. Cox proportional hazards models evaluated time-to-event outcomes. Among patients with latent infection, 494 received corticosteroids, and 1,501 did not. After matching, corticosteroid exposure was associated with increased 90-day mortality (9.4% vs. 4.7%; OR 2.10, 95% CI 1.19-3.72), sepsis (OR 2.05, 95% CI 1.17-3.58), bacteraemia (OR 2.13, 95% CI 1.41-3.23), and ICU admission (OR 2.85, 95% CI 2.03-3.98). In Cox models, corticosteroid exposure remained independently associated with higher hazards of 90-day mortality (HR 3.16, 95% CI 2.01-5.02) and sepsis (HR 3.01, 95% CI 1.72-5.23). Prophylactic ivermectin was associated with a lower risk of a composite outcome (12.9% vs. 27.1%; OR 0.40, 95% CI 0.18-0.89). These findings support enhanced screening and preventive strategies in at-risk patients.