Strongyloides stercoralis hyperinfection masquerading as cerebral vasculitis

Strongyloides stercoralis hyperinfection is a unique opportunistic infection in which the nematode disseminates widely to cause a multisystem illness. We treated a patient with systemic lupus erythematosus in whom ileus and fever developed and who later lapsed into coma. A xenon Xe 133 cerebral blood flow study showed a global reduction in flow, compatible with CNS vasculitis. The patient's condition failed to improve with high-dose steroid therapy, but he recovered rapidly after Strongyloides larvae were found in stool and sputum and treatment with thiabendazole was begun. We believe that hyperinfection explained the patient's symptoms and should be considered as a cause of diminished cerebral perfusion and mentation in immunosuppressed patients.