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Title : A 62-year-old male w/ dyspnea
Date : November 13, 2008
Contributed by

Hae Suk Cheong, M.D. Samsung Medical Center, Seoul, Korea

Patient History
Age/Sex A 62-year-old man
Chief complaint dypnea
Present illness

Eight days before admission, abdominal pain,nauasea and vomiting developed. On admission day, he had a mild direct tenderness on upper abdomen on the physical examination. A CT study of abdomen showed a gallbladder distension with mild wall thickening. The patient was started on ceftriaxone and metronidazole for treatment of presumed acute cholecystitis(Figure 1 : Chest-X-ray on admission). On the second hospital day, dyspnea developed. The temperature was 36.4, the pulse rate 121 beats per minute, and the respiratory rate 28breaths per minute. The blood pressure was 129/83mmHg. The oxygen saturation was 83% percent whlie the patients breaths ambient air.

Past medical history

Three month earlier, she had diagnosed small cell lung cancer. A chemotherapy course of etoposide and cisplatin was began, followed by fourth chemotherapy until 10 days before admission.

Physical examination

The patient appeared acute ill-looking. Lung auscultation revelaed crackles at the right lower lung.

Initial laboratory findings

The CBC revelaed 5200>8.7<41K (Eosinophil 10%). The ESR was 30mm/hr and CRP was 18.7 mg/dl. The level of total bilirubin, glucose, urea nitrogen and creatinine were normal.

Radiologic findings

The Chest X-ray showed right-side pulmonary infiltrates (Figure 2: Chest X-ray on second hospital day).
Computered tomograpy (CT) showed a ground-glass apperance on right lung (Figure 3).

Hospital course

The patient were transfered to the intensive care unit and underwent a bronchoscopy with bronchoalveolar lavage. Bacterial, viral, Pneumocystis jiroveci, and fungal cultures were all negative. The ceftriaxone and metronidazole were changed to cefepime,azithromycin and metronidazole. On the thrid hospital day, Escherichia coli were isolated on blood culture which performed on admission day. His repiration aggraveted and intubation and mechanical ventilation were performed.

Question - ID Case of the Week ( November 13, 2008 )
What is your impression?
Correct Answer

Strongyloides stercoralis, hyperinfection, lung

--> diagnosed by examination of BAL fluid


Strongyloides stercoralis
-  Common enteric helmointhic parasite of worldwide

-   Immunocompetent host : asymptomatic or manifest as mild GI symptoms
     Immunocompromised host : devastating and 60-85% mortality rate

- Life cycle
   Strongylodes larvae exist in 2 forms
         --> 1) Filariform infective larvae
               2) Free-living rhabdiform larvae

- Hyperinfection
   The syndrome of accelerated autoinfection
          <-- result of an alteration in immune status

- Clinical manifestations

Organ system Symptoms Signs
Skin Pruritis,eruption urticaria,angioedema, larva currens, eruption
GI abdominal pain, diarrhea, nausea,vomiting weight loss, malabsortion, epigastric tenderness
Pulmonary wheezing, cough, hemoptysis,shortness of breath wheeze,rales
CNS headache, altered mental state, focal seizures, coma meningeal signs, disorientation
Immune/Allergic urticaria, anaphylaxis urticarial rash, larva currens rash
Hematologic fever, chills, rigors tachycardia, bacteremia, septicemia, eosinophilia
Other(rare) peritonitis, endocarditis, eosinophilic pleural effusion, eosinophilic granulomatous enterocolitis  


- Diagnosis
 Sensitivity of stool exam is poor (50% with three stools) unless hyperinfection present
    --> can be increase with stool concentration or blood agar culture 
   --> can be isolated from virtually any body fluid with dissemanated disease
 Serology is sensitive but not specific
 Eosinophilia often absent in hyperinfection

 Ivermectin 200ug/kg daily
   -- uncomplicated : 2 days
   -- complicated : treat until resolution  


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