A83-02 Strongyloides Leading to Acute Respiratory Distress Syndrome: Challenges With Steroid Management

Introduction

Strongyloides stercoralis infection is often asymptomatic but can progress to life-threatening hyperinfection in immunocompromised patients. Corticosteroid exposure is a well-recognized trigger for worsening disease. This case highlights the diagnostic challenges and management considerations when Strongyloidiasis complicates acute respiratory distress syndrome requiring steroid therapy.

Description

A 75-year-old woman presented with acute hypoxemic respiratory failure thought to be secondary to anaphylactic shock from an epidural steroid injection she received few hours prior. She was started on IV steroids for anaphylaxis. Physical exam was notable for a transient erythematous rash, initially concerning for urticaria. Her labs were notable for a reduced absolute CD4 count (41 cells/uL) but negative for HIV and HTVL-1. Chest imaging demonstrated diffuse, bilateral ground-glass opacities. Empiric treatment for bacterial pneumonia was initiated without improvement. She did not tolerate non-invasive positive pressure ventilation and was subsequently intubated secondary to progressive hypoxemic respiratory failure in the setting of acute respiratory distress syndrome (ARDS). Dexamethasone was initiated for ARDS. Bronchoscopy with bronchoalveolar lavage grew candida albicans in the fungal culture. On further review, the patient was noted to have marked eosinophilia (5,490 cells/uL) two weeks prior to admission. Strongyloides antibody testing was ordered and found to be positive. Stool ova and parasites smear identified Strongyloides stercoralis rhabditiform larvae. BAL cytology also identified a few nematode larvae, morphologically consistent with Strongyloides species. The patient was initiated on IV and subcutaneous (obtained through compassionate use) ivermectin, albendazole, and systemic corticosteroids were slowly tapered. The patient’s oxygenation improved, and subsequent chest radiographs revealed interval improvement. Repeat stool ova and parasites was negative. The patient’s hospital course was complicated by persistent fevers and worsening encephalopathy, raising concern for CNS involvement of Strongyloides. Despite continued treatment, the patient’s neurological status failed to improve, and the family elected to pursue comfort-focused measures.

Discussion

Strongyloides stercoralis infection may remain clinically quiescent but can lead to life-threatening hyperinfection in immunocompromised hosts, particularly after corticosteroid exposure. In this case, the patient’s unexplained eosinophilia and IV steroids for anaphylaxis were key diagnostic clues that prompted further investigation. In patients with ARDS of unclear etiology, Strongyloides infection should be considered particularly before initiating corticosteroids, especially as steroids have become a cornerstone therapy for ARDS. Early identification and prompt treatment with ivermectin, often in combination with albendazole, alongside judicious steroid tapering, are critical to improving outcomes.

This abstract is funded by: n/a