key: cord-0050071-2rzszcke
authors: Kumar, Anil; Paulose, Roopa; Sadasivan, Shine; Bajad, Chandan; Ramachandran, Arya; Nair, Priya
title: Sarcoidosis, Steroids and Strongyloides -What’s the Catch?()
date: 2020-09-17
journal: Clin Microbiol Infect
DOI: 10.1016/j.cmi.2020.09.012
sha: e819ed3a09b440ead53bdbafbc319f9063f2627d
doc_id: 50071
cord_uid: 2rzszcke

nan

A 55-year-old male, who is a known case of sarcoidosis, on steroids for the last 13 years, presented with weight loss for the last 2-3 months, loss of appetite, intermittent loose stools, abdominal discomfort, and frequent flatulence.

Colonoscopy showed aphthous ulcers in the rectum, descending, transverse, ascending colon as well as splenic, and hepatic flexures (see Supplementary material, Video S1). Histopathologic examination of biopsy from the ulcerated mucosa showed dense infiltrate of eosinophils in the lamina propria, associated with patchy ulceration, and S. stercoralis in the mucosal crypts. Stool examination showed plenty of rabditiform larvae of S. stercoralis . The patient was diagnosed with hyperinfection syndrome due to S. stercoralis. S. stercoralis is an intestinal pathogen seen both in immunocompetent as well as individuals with defects in cellmediated immunity [1] . Three 2-day courses of ivermectin 200 µg/kg/day, every 15 days, resulted in a full symptomatic resolution.

Chronic gastrointestinal infection with S. stercoralis can have either no symptoms or mild nonspecific gastrointestinal, respiratory, and cutaneous symptoms. The increased larval burden can lead to complications such as ileus, gastrointestinal bleeding, intestinal obstruction, and even death. Alteration of immune status results in increases larval load, leading to hyperinfection syndrome. There is exacerbation of gastrointestinal and pulmonary symptoms which is evidenced by demonstration of larvae in the stool and /or sputum [1] . Moreover, the migration of larvae outside the gastrointestinal and respiratory tracts can be observed, causing extrapulmonary and extra-intestinal signs/symptoms.

Among the immunosuppressive drugs, glucocorticoids are the most specifically associated with transforming chronic strongyloidiasis to hyperinfection [1] . Hyperinfection can result from high-dose steroids, low-dose steroids, and even locally injected steroids [1] . Signs and symptoms usually begin as early as 20 days after the onset of steroid therapy, and as late as several years without an obvious additional immunocompromising condition supervening [1] . It is important for clinicians to rule out gastrointestinal infection with S. stercoralis in patients on long term steroids in order to prevent hyperinfection syndrome. In hyperinfection the diagnosis is easily made by stool examination, while in chronic uncomplicated infection, stool examination might result in a disappointing high proportion of false negatives. Hence, screening of at-risk patients should include other specific tests for S. stercoralis (for instance stool culture, Baermann test, PCR, and/or serology). With dexamethasone becoming standard of care for severe COVID-19, the risk of strongyloidiasis reactivation should be considered. It would be worth investigating whether the recommended low-dose short-course really brings higher risk for hyperinfection syndrome due to S. stercoralis.

AK: Conceptualization, Supervision, Validation, Investigation, Writing -original draft. RP: Resources, Visualization, Investigation, Writing -review & editing. SS: Resources, Visualization, Investigation, Writing -review & editing. CB: Investigation, Writing -review & editing

AR: Investigation, Writing -review & editing

PN: Visualization, Investigation, Writing -review & editing

Strongyloides stercoralis infection in the immunocompromised host

Legend: Figure A. Colonoscopy showing aphthous ulcers in colon

Colonic biopsy on histopathology (hematoxylin and eosin) showing eosinophilic colitis with Stronglyloides stercoralis in the mucosal crypts

Stool examination showing rabditiform larvae of Stronglyloides stercoralis (400X)

Video of colonoscopy showing biopsy of the ulcers.