Hyperinfection with Strongyloides in a HIV-negative elderly male
A 70-year-old male was brought to the emergency department with complaints of increasing difficulty in breathing, cough with expectoration and fever of about one-week duration. The patient was suffering from cough with expectoration, breathlessness on and off for the past two years and vague abdominal discomfort for the past six months. The patient was not a diabetic or hypertensive but smoker for the past 40 years. On examination, the patient was thin built, ill-looking and pale. His pulse rate was 86/min and blood pressure was 140/80 mm of Hg. On palpation, the abdomen was tender in the epigastric and right hypochondriac region. There was no evidence of lymphadenopathy. Papules and excoriations were seen over the perianal region. The patient was conscious and coherent. No abnormality of central nervous system (CNS) was noted. Normal vesicular breathing with rales and course crackles were found in both the lung fields. Examination of cardiovascular system (CVS) was unremarkable.\nAt the time of admission, random blood sugar was 85 mg/dl, blood urea - 44 mg/dl, creatinine - 4 mg/ dl, hemoglobin - 9.3 g/dl, total count - 7200 cells/cmm, differential count- P67%, L29%, E04%, absolute esinophil count - 480 cells/cmm, erythrocyte sedimentation rate -10 mm and 24 mm at half an hour and one hour respectively. Serum sodium was 123 mmol/l, serum potassium - 3.3 meq/l, chloride - 89 meq/l and bicarbonates- 26 meq/l. Mantoux test and test for anti-human immunodeficiency virus (HIV) antibodies were negative. Electrocardiogram showed sinus tachycardia. Chest X-ray was suggestive of multiple fluid-filled cavities in the left lung and pending the results of sputum examination, the patient was empirically put on injection deriphylline, amoxycillin-clavulanic acid, gentamicin, ranitidine and metronidazole with a provisional diagnosis of acute exacerbation of chronic obstructive pulmonary disease (COPD)/lung abscess.\nOn day three of admission, the patient continued to have difficulty in breathing. Physical examination showed bilateral wheeze and no other abnormality. Electrocardiogram (ECG) showed sinus tachycardia. The patient was put on increasing dose of bronchodilators following which he appeared to be relieved temporarily. SPO2 was 96% without O2 Sputum for acid fast bacilli (AFB) was negative on three consecutive days. Wet mount of the sputum showed plenty of actively motile larvae of S. stercoralis [, ]. Routine culture of sputum yielded a moderate growth of Escherichia coli which was susceptible to gentamicin and amikacin. Examination of stool and repeat sputum was requested by our laboratory following the detection of larvae in the sputum. Stool sample and sputum sample collected on two consecutive days showed plenty of motile larvae of S. stercoralis []. The patient was put on albendazole 400 mg bid for three days. Repeat chest X-ray showed persistence of lung abscess on the left side. Ivermectin 12 mg OD was subsequently added to the treatment regimen and albendazole continued for further three days. Repeat stool examination done on the two consecutive days did not show any larvae of S. stercoralis. Sputum could not be examined as the patient could not submit the sample as there was no expectoration. Repeat chest X-ray showed clearance of fluid in the lung abscess with only thick fibroid wall of the cavity. He became afebrile and appetite improved. The patient was feeling better and was discharged at request with advice to report after two weeks. Follow-up of the patient four weeks later showed the patient was asymptomatic and stool examination did not show any parasites.