Abstract
Strongyloides stercolis is an intestinal helminth which predominantly causes disease in the tropics and subtropics. Immunocompetent patients can remain asymptomatic, but immunocompromised patients can develop hyperinfection syndrome, in which the parasite reproduces and disseminates rapidly, leading to multi-organ failure and death. We present a case of Strongyloides hyperinfection syndrome (SHS) likely triggered by HTLV1 infection and pregnancy. Patients infected with HTLV-1 have increased T-regulatory cells and impaired Th2 response (decreased production of IL4,5,13 and decreased eosinophil recruitment), leading to impaired larvae killing, favoring parasite proliferation. This is a 38-year-old Ethiopian female who presented at 24 weeks gestation with lethargy and dyspnea in the setting of three weeks of nausea, vomiting, and diarrhea. She was admitted to the intensive care unit for shock, disseminated intravascular coagulation, and multi-organ failure requiring intubation and urgent c-section delivery. Dermatology was consulted for a three-day history of abdominal purpura consistent with periumbilical thumbprint purpura seen in SHS. A punch biopsy of the left lower abdomen showed features consistent with infestation. The diagnosis was confirmed with positive strongyloides antibody serologies. She was started on ivermectin followed by albendazole, given severity of disease. While hospitalized, she underwent extensive infectious work-up revealing HTLV-1 antibody positivity. She underwent flow cytometry of the peripheral blood, which revealed 12% abnormal T-cells with loss of CD7 and CD26, as well as clonal TCR rearrangement, concerning for adult T-cell leukemia/lymphoma (ATLL). Ultimately, the patient slowly recovered and was successfully discharged. She continues to follow up with medical oncology for chronic ATLL.
