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Strongyloides Hyperinfection Presenting as Acute Respiratory Failure and Gram-Negative Sepsis^*

^* From the Department of Medicine (Dr. Newberry), Hennepin County Medical Center, Minneapolis; Department of Medicine, Infectious Disease and International Medicine (Drs. Williams, Stauffer, and Boulware), and Department of Pediatrics (Dr. Hendel-Paterson), University of Minnesota, Minneapolis; and Regions Hospital/HealthPartners (Dr. Walker), Department of Medicine, Center for International Health, St. Paul, MN.

Correspondence to: William Stauffer MD, Attn: Conni Conner, Regions Hospital, Center for International Health, Mail Stop 11503F, 640 Jackson St SE, St. Paul, MN 55101; e-mail: stauf005{at}umn.edu

Study objectives: Disseminated strongyloides is a rarely reported phenomenon and occurs in immunosuppressed patients with chronic Strongyloides stercoralis infection. Typically, patients present with pulmonary symptoms but subsequently acquire Gram-negative sepsis. Several cases have been noted in Minnesota, and their presentation, diagnostic evaluation, and clinical outcomes were reviewed.

Design: A retrospective chart review was conducted of complicated strongyloides infections from 1993 to 2002 in Minneapolis and St. Paul, MN. Cases were identified by reviewing hospital microbiology databases.

Setting: Metropolitan hospitals with large immigrant populations.

Results: Nine patients, all of Southeast Asian heritage, were identified. Eight patients immigrated to the United States 3 years prior to acute presentation. All patients were receiving antecedent corticosteroids; in five patients, therapy was for presumed asthma. Absolute eosinophil counts > 500/µL occurred in only two patients prior to steroid initiation. Eight patients presented with respiratory distress, and Gram-negative sepsis developed in four patients. Four patients had evidence of right-heart strain on ECG or echocardiography at the time of presentation. Three patients died; all had eosinophil counts of < 400/µL.

Conclusions: Serious complications, including death, may occur in patients with chronic strongyloides infection treated with corticosteroids. Strongyloides hyperinfection usually presents as acute respiratory failure and may initially mimic an asthma exacerbation or pulmonary embolism. Southeast Asian patients presenting with new-onset "asthma," acute respiratory distress, and/or Gram-negative sepsis should undergo evaluation to exclude strongyloides infection.

Key Words: acute respiratory failure • disseminated strongyloides • Gram-negative sepsis • Strongyloides stercoralis

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