Introduction• Severeeosinophilia is defined as the association of high numbers of eosinophils (>5000 x 10^3 cells/uL) in the peripheral blood.
• Whencaused by Strongyloidiasis in an immunocompromised host, the elusive nature ofthe parasite is an obstacle for establishing a diagnosis. • StrongyloidiasisStercoralis is considered a marker to evaluate the immunosuppressed state ofpatients with impaired cell mediated immunity in many countries. The vastmajority if not all of Strongyloidiasis cases that are documented are found inpatients that are extremely immunosuppressed, most commonly accompanied byspecific risk factors, and present as chronic low-intensity infections whichpresent as asymptomatic while still remaining dangerous due to the potential ofdeveloping fatal disseminated forms.
• Althoughreactivation of a latent infection is rare and scarce in literature; cases havebeen documented where organ recipients who were negative for IgG levels beforetransplantation received an organ from an IgG positive donor and severedisseminated forms of Strongyloidiasis occurredGB1 . Case• Wepresent for your consideration GB2 the case of a 63-year-old manwith history of liver transplant performed in July 2015 with no record ofrejection and a positive response to Tacrolimus and Corticosteroidimmunosuppressive therapy.• A right nephrectomy was performed on January2017 due to a primary renal pelvis carcinoma discovered by CT-Scan; withevidence of metastasis to the lungs, liver, and bone, for which he received hisfirst round of chemotherapy. • Shortlyafter his first cycle of chemotherapy he was found with incidental leukocytosis(88.59 x 10^3 cells/mL) and severe eosinophilia(67.
33 x 10^3 cells/mL) in a control work-up;which was associated with skin eruption and pruritus, lower back and glutealpain secondary to metastatic disease. • Helived in Caguas his whole life, and worked as telephone and cable specialist.He traveled to the Dominican Republic constantly; last trip was reported to beduring 2014.
He also had history of alcoholism and smoking prior to transplant.• Hewas treated with Cefepime to resolve his Gram negative bacteremia with reportedE.Coli predominance and vast susceptibility to antibiotics. • Prednisoneand Tacrolimus were placed on hold when the eosinophilia emerged.
• Completedeosinophilia workup during his inpatientGB3 period.• Hewas started on Hydroxyurea and after his leukocytes were seen on a decreasingtrend he was discharged home on the medication. • Theeosinophilia workup showed positive Strongyloides IgG; hence GB4 the treatment was initiatedwith Ivermectin which had a positive response as evidenced by the gradual decreasingvalues of eosinophils. Discussion • Strongyloidiasisrarely presents as reactivation of a latent infection and in this case wherethere has been no known exposure to the parasite. GB5 Clinical manifestations atthe initial stage of Strongyloidiasis vary from urticaria, generalizedpruritus, to abdominal pain.
This patient presented pruritus and skin eruptionafter his first round of chemotherapy. No other noticeable symptoms, manifestationsor signs in contrast to laboratory results other than high eosinophilic valuesover 20,000 in the peripheral blood were found; high IgE levels and a positiveStrongyloides Stercoralis IgG.• Thedetection of Gram negative bacteremia with E.Coli was a pivotal sign thatpointed towards the diagnosis of Strongyloides; which is usually the result oflarvae penetrating through the intestinal wall contaminating the exterior withthe intestinal flora. • Wepropose the possibility of 3 ways of infection: reactivation of a latentinfection, exposure to the parasite recently, or the result of organtransplantation; hence our motives of presenting the case being that the incidenceand prevalence of the parasite remains unknown in Puerto Rico. • Othercomplications such as hyper-infection syndrome and disseminatedStrongyloidiasis could have easily presented in this patient due to themultiple present risk factors.
• Thepossibilities of identifying the etiology of this patient’s infection areminimal due to: no history of exposure to the parasite, and secondly theabsence of Strongyloides screening in the actual organ transplant protocolapproved by the American Society of Transplantation. Conclusion• Thiscase raised awareness of the potential of development of severe anddisseminated forms of Strongyloidiasis in patients who have traveled to, livedin any endemic area; or patients with fluctuant eosinophilia, since unlikeother intestinal parasites, Strongyloides may remain latent for years, and thepresence of eosinophilia could be the only sign of infection. • Eversince the Organ Transplant Department of Hospital Auxilio Mutuo has started itsoperations there has not been any documented cases of Strongyloidiasis in apost-transplanted patient. This investigation has raised awareness of the riskof Strongyloidiasis in the institution and it has helped implement screeningmeasures, even when the protocol for organ transplantation established by theAmerican Society of Transplantation does not include any screening forStrongyloides Stercoralis in non-endemic areas. References.
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