Board Review Questions of the Week – Immunocompromised Patient

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This week’s case-based question:


A 52-year-old man with a status of 21 days post–renal transplant is taking glucocorticoids and calcineurin inhibitors. He presents with altered mental status, dyspnea, cough, hemoptysis, eosinophilia (40%), fever, nausea, vomiting, rash, and diarrhea with intermittent hematochezia. The patient’s bronchoalveolar lavage, blood cultures, cerebrospinal fluid (CSF) cultures, and stool samples are all significant for the presence of filariform larvae (see Figure).

Figure.

In addition, gram staining of the blood and CSF samples are significant for gram-negative organisms. The patient quickly progresses to respiratory distress syndrome and is transferred to the intensive care unit.

Which statement correctly describes this pathogen?

Answer Options

The infection is most commonly donor-derived in nature.
In the process of autoinfection, adult females reside in the lungs.
It may be associated with enteric gram-negative bacteremia and meningitis.
There is no impact on the pulmonary system in the immunocompromised patient.

And the answer is …


Correct Answer:

It may be associated with enteric gram-negative bacteremia and meningitis.

Educational Objective:

Discuss the presentation of strongyloidiasis in patients who are immunocompromised.

Key Point:

Strongyloidiasis may present with a serious hyperinfection in an immunocompromised host. The infection demands immediate medical therapy, and ivermectin is the agent of choice.

Explanation:

Disseminated Strongyloides hyperinfection is associated with enteric gram-negative bacteremia and meningitis in patients following solid organ transplantation, as well as in patients with other causes of immunosuppression. The mechanism involves the transport of normal enteric flora from the gut to the lymphatic or mesenteric circulation through the process of worm migration through tissues. Ivermectin plus broad-spectrum empiric antibiotic therapy with gram-negative coverage (e.g., tigecycline) should be initiated as soon as possible.

The infection is most often derived from the recipient, who is often from a region endemic with S. stercoralis. In the process of autoinfection, adult females, which are present in the intestines, lay eggs that form rhabditiform larvae. These larvae eventually form the filiform larvae that may migrate through the intestines into the lymphatics and mesenteric system, thereby gaining access into the general circulation with subsequent spread to the lungs, liver, kidneys, and gallbladder. When they are present in the lungs, the filiform larvae can cause autoinfection and regain access to the bowel. This process is aggressively accelerated in immunosuppression, resulting in a staggering number of filiform larvae at every stage.

In the immunocompromised patient, the pulmonary system may undergo rapid decompensation with subsequent respiratory distress syndrome. In addition, granulomas and abscess formation may develop, thus, the pulmonary system may be involved.

References:

Chokkalingam Mani B, Mathur M, et al. Strongyloides stercoralis and organ transplantation. Case Rep Transplant. 2013;2013:549038.

Mazhar M, Ali IA, Higuita NI. Strongyloides hyperinfection in a renal transplant patient: always be on the lookout. Case Rep Infect Dis. 2017;2017:2953805.

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