Our patient improved over the next 10 days and was discharged in good condition to complete a total of 4 weeks of daily oral ivermectin therapy. S. stercoralis, an intestinal nematode endemic to Africa, Southeast Asia, Central and South America, has a complex life cycle involving the pulmonary and gastrointestinal

systems. 1 Infection is often asymptomatic. Symptomatic disease ranges from nonspecific cutaneous, gastrointestinal, and respiratory manifestations to an often fatal hyperinfection syndrome. Pulmonary symptoms include cough, dyspnea, wheezing, and hemoptysis. An asthma-like syndrome can be seen with chronic Strongyloides infection. Respiratory symptoms are thought to be caused by larval migration across SCR7 cell line alveolar-septal walls, larval maturation in pulmonary parenchyma, or widespread dissemination during the hyperinfection syndrome. 2 A hyperinfection syndrome occurs when decreased cell-mediated immunity enables accelerated

autoinfection, causing widespread parasitemia. Risk factors for hyperinfection include corticosteroids, stem-cell transplantation, alcoholism, HIV, and HTLV-1 infection. Common manifestations include fever, abdominal pain, anemia, and diarrhea.3 and 4 Gram-negative bacteremia see more is a frequent complication, resulting from bacterial translocation in the intestine due to mucosal disruption by Strongyloides larvae. Pulmonary symptoms develop in 85% of hyperinfection patients.2 Manifestations include pulmonary infiltrates, DAH, and respiratory failure, all of which developed in our patient. Though she also had E. coli bacteremia, we believe this was due to urosepsis rather than Benzatropine intestinal translocation. S. stercoralis

hyperinfection carries a high mortality rate of 70–89% in modern series. 1, 3 and 4 All cases complicated by DAH in the medical literature have reported fatal outcomes. Detection of disseminated disease requires high clinical suspicion. Diagnosis is often made by identification of larvae in stool, sputum, or BAL fluid. Ivermectin or albendazole are first-line treatments for uncomplicated infection. In disseminated disease, optimal treatment remains uncertain. Oral ivermectin may be ineffective due to ileus associated with hyperinfection syndrome. Thus, subcutaneous ivermectin has been used in cases of disseminated Strongyloides. 5 It is unclear why our patient developed the hyperinfection syndrome during this admission since she had been on corticosteroids for the preceding 3 months. It is possible that the administration of IV methylprednisolone on admission resulted in further immunosuppression and precipitated her deterioration. Our patient improved dramatically after treatment with oral and subcutaneous ivermectin. She represents the first case of survival in DAH from disseminated Strongyloides. In spite of this success, the ideal treatment for disseminated strongyloidiasis remains unknown.