Abstract

A 63-year-old male Cuban immigrant presented to the emergency room with visual changes and right-sided weakness. He had a history of chronic tobacco use, peripheral eosinophilia, and a right upper lobe lung nodule. Computed tomography (CT) demonstrated a left occipital brain mass with midline shift and he was started on dexamethasone with planned outpatient malignancy workup. Two months later, he presented with acute onset shortness of breath, confusion, and severe abdominal pain. He was admitted to the intensive care unit for acute hypoxic respiratory failure and septic shock requiring intubation and pressor support. CT imaging showed multifocal pneumonia and small bowel obstruction with signs of bowel ischemia for which he underwent small bowel resection and anastomosis. In the post-operative period, the patient developed thumbprint-appearing retiform purpura on the abdomen and upper thighs that was clinically concerning for disseminated strongyloidiasis. He was started on ivermectin 200 mcg/kg. A punch biopsy revealed filariform larvae in the dermis and subcutis consistent with Strongyloides stercoralis. They were subsequently appreciated on review of the small bowel sample and on bronchoscopy. Cytology from bronchoalveolar lavage was negative for malignancy. The species was confirmed with stool culture and serology.  Due to malabsorption, the patient was started on rectal ivermectin and oral albendazole was added for better CNS penetration. Unfortunately, the patient’s clinical status remained unchanged and he was transitioned to comfort-focused care and then expired. This case highlights the clinical and histological signs of disseminated strongyloides infection to aid diagnosis and guide prompt treatment.