Post-Renal Transplant Miliary Mottling: Not Always Tuberculosis

Strongyloides stercoralis combined with concurrent multiple pathogens infections in an immunosuppressed patient: a case report

Background

Strongyloides stercoralis is an opportunistic pathogenic parasite. Most individuals with normal immune function may not exhibit significant symptoms, and the signs are atypical, which can easily lead to missed diagnoses and delayed treatment. People with underlying diseases and weakened immunity are prone to develop severe conditions after infection with Strongyloides stercoralis.

Case presentation

We report an immunocompromised patient in whom the pathogen was initially not detectable using traditional parasitic detection techniques. However, Strongyloides stercoralis was identified in both the alveolar lavage fluid and blood through metagenomic next-generation sequencing. Subsequently, Strongyloides stercoralis was detected in the alveolar lavage fluid after multiple rounds of testing using traditional microscopic examination techniques. Based on the mNGS results and other examination findings, the patient was diagnosed with Strongyloides stercoralis in combination with concurrent multiple pathogens infections. After the combined drug therapy of Meropenem, Vancomycin, and Albendazole, the patient's condition was gradually brought under control.

Conclusion

This case demonstrates the advantage of integrating traditional detection methods with metagenomics next-generation sequencing technology in the etiological diagnosis of immunocompromised individuals. It is conducive to clarifying the etiological diagnosis of patients and thereby facilitating the timely initiation of corresponding treatments.

Overlapping Infection by Strongyloides spp. and Cytomegalovirus in the Immunocompromised Host: A Comprehensive Review of the Literature

Strongyloides and cytomegalovirus co-infections are rarely reported, even though they are distinguished by high morbidity and mortality, especially in immunocompromised hosts. We narratively reviewed the literature on reported cases of Strongyloides and CMV co-infections in immunosuppressed patients. Most cases occurred in males with a median age of 47 (IQR, 37-59). Strongyloides/CMV co-infections occurred among immunocompromised hosts, especially in solid organ transplants and hematological or rheumatological diseases. Most of the patients underwent a course of steroid treatment before the diagnosis of co-infections. Other common immunomodulatory agents were tacrolimus and mycophenolate. The first clinical manifestations of co-infections were mainly gastrointestinal, followed by respiratory symptoms. CMV was, in most patients, co-infected with an isolated reactivation, although Strongyloides manifested especially as hyperinfection syndrome. Ganciclovir and ivermectin are the mainstays of CMV and Strongyloides treatment. However, the treatment mortality reported in this narrative review is around 52.4%. Interestingly secondary bacterial infections are common in CMV/Strongyloides-infected patients.

A comprehensive review of Strongyloides stercoralis infection after solid organ and hematopoietic stem cell transplantation

BACKGROUND

We reviewed the scientific literature to gain insight on the epidemiology and outcome of Strongyloides stercoralis infections after transplantation.

METHODS

CINAHL, PUBMED, and OVID/MEDLINE were reviewed from inception through March 31, 2022 using key words Strongyloides and transplantation.

RESULTS

Our review identified 108 episodes of Strongyloides infection among 91 solid organ transplant (SOT) and 15 hematopoietic cell transplant (HCT) recipients. Median time to infection was 10.8 (range, .14-417) and 8.8 (range, 0-208) weeks after SOT and HCT, respectively. Gastrointestinal symptoms were frequent (86/108 [79.6%]), while skin rash (22/108 [20.3%]) and fever (31/103 [30%]) were less common. Peripheral eosinophilia was observed in half of patients (41/77 [53.2%]). Bacteremia (31/59 [52.5%]) was frequently due to Gram-negative organisms (24/31 [77.4%]). Abnormal chest radiologic findings were reported in half (56/108 [51.9%]). The majority had hyperinfection syndrome (97/108 [89.8%]) while disseminated strongyloidiasis was less common (11/108 [10.2%]). Thirty-two cases were categorized as donor-derived infection (DDI), with donors (23/24 [95.8%]) who had traveled to or lived in endemic areas. Median time to DDI was 8 weeks (range .5-34.3 weeks) after transplantation. Treatment consisted of ivermectin (n = 26), a benzimidazole (n = 27), or both drugs (n = 28). There was high all-cause mortality (48/107, 44.9%) and a high Strongyloides-attributable mortality (32/49, 65.3%).

CONCLUSIONS

Strongyloidiasis should be strongly considered among recipients with epidemiologic risk factors for infection, even in the absence of eosinophilia or rash. A policy that provides guidance on pro-active screening is needed, to ensure preventive measures are provided to recipients at increased risk.