Liu Hsu-Chung, Hsu Jeng-Yuan, Chang Ki-Ming
Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, R.O.C.
J Chin Med Assoc. 2009 Aug;72(8):442-5. doi: 10.1016/S1726-4901(09)70403-4.
Hyperinfection syndrome with Strongyloides stercoralis is not uncommon in immunocompromised patients. We present 2 fatal cases of Strongyloides hyperinfection with initial presentation mimicking acute exacerbation of chronic obstructive pulmonary disease (COPD). Both cases had a history of COPD and had received systemic steroid treatment before or during admission. The initial chest radiograph in both of these cases showed diffuse axial interstitial pattern. The sputum examinations of Gram stain both yielded larvae of Strongyloides stercoralis precipitously. Case 1 developed acute respiratory distress syndrome and bacteremia of Escherichia coli and Klebsiella pneumoniae soon after admission, and died even after receiving albendazole and antibiotic treatment. Case 2 received albendazole and antibiotic treatment for over 2 weeks, but developed refractory aseptic meningitis and died of septic shock. Neither case had high eosinophil count in peripheral blood during admission. Clinical manifestations of unexplained wheezing and respiratory failure, increased infiltration on chest radiograph, Gram-negative bacteremia, and aseptic meningitis may all be clues of Strongyloides hyperinfection. Due to the high mortality rate and severe complications in these patients, clinicians should always keep this diagnosis in mind, especially when dealing with immunocompromised patients. We suggest that a screening test be done for patients who live in endemic areas and those who are going to receive steroids for chronic disease.
粪类圆线虫引起的重度感染综合征在免疫功能低下患者中并不少见。我们报告2例粪类圆线虫重度感染的致死病例，其最初表现类似于慢性阻塞性肺疾病（COPD）急性加重。这2例患者均有COPD病史，且在入院前或入院期间接受过全身类固醇治疗。这2例患者最初的胸部X线片均显示弥漫性轴位间质模式。这2例患者的痰液革兰氏染色检查均迅速发现粪类圆线虫幼虫。病例1入院后不久即出现急性呼吸窘迫综合征以及大肠杆菌和肺炎克雷伯菌菌血症，即使接受阿苯达唑和抗生素治疗后仍死亡。病例2接受阿苯达唑和抗生素治疗2周以上，但出现难治性无菌性脑膜炎，最终死于感染性休克。这2例患者入院期间外周血嗜酸性粒细胞计数均不高。无法解释的喘息和呼吸衰竭、胸部X线片上浸润增加、革兰氏阴性菌血症和无菌性脑膜炎等临床表现均可能是粪类圆线虫重度感染的线索。由于这些患者死亡率高且并发症严重，临床医生应始终牢记这一诊断，尤其是在处理免疫功能低下患者时。我们建议对生活在流行地区以及即将因慢性病接受类固醇治疗的患者进行筛查。
