Ready for a #tweetorial? 68 yo man from Ecuador #COVID-19 positive, got tocilzumab and 3 courses of methylpred, HD12 became bacteremic with Strep constellatus and Citrorbacter freundii, HD 18 grew some Pseudomonas and MSSA in the sputum but the chocolate agar also showed this:
What other organism is in the sputum?
You all got it 🙂 The answer is Strongyloides stercoralis and the patient has Stronge hyperinfection syndrome. They later had a gram stain of the sputum that showed a first-stage rhabditiform larava (300 micrometer), check it out!
The genus can be discerned by looking closely: a short buccalcanal and prominent genital primordium consistent with Strongyloides species.
Stronge is only helminth where you can have autoinfection, all the others you don't have to worry about. Here you can see the classic CDC diagram where adults living in a humans intestine can make eggs that either leave via the stool OR invade the gut as rhabditiform larvae
Because of this auto-infection you can be at risk for hyper infection syndrome years after leaving an endemic area, for example this patient moved from Ecuador 20 years ago
Steroids is a well known risk factor for hyperinfection syndrome likely due to inhibition of eosinophils and lymphocytes. It is not known yet if tocilizumab would put a patient at increased risk for this.
This patient was treated initially with ivermectin but with lack of clinical response and CXR showing unchanged mutlifocal bilateral pulmonary opacities (also a classic finding in this syndrome), albendazole 400 mg q 12 hr was added as an adjunctive therapy.
Also final reminder, if a patient with stronge hyperinfection syndrome has AMS be sure to get an LP to see if there is evidence of meningitis and or larvae in the CNS, cause we don't want to miss that
And that is it! If you want more check out the whole case! https://www.ajtmh.org/content/journals/10.4269/ajtmh.20-0699