An 85-year-old woman with failure to thrive due to poor oral intake was admitted owing to dehydration. A nasogastric (NG) tube was inserted for the initiation of enteral feedings. The tube position was confirmed by gastric auscultation after insufflating air through the tube. A chest X-ray revealed that the NG tube traversed the right main stem bronchus with its tip ending in the right costophrenic angle adjacent to the pleura. No pneumothorax was identified. The tube was removed and a short while later the patient developed mild chest discomfort. A repeat chest X-ray revealed significant pneumothorax on the right side. She was treated conservatively with 100% oxygen with successful resolution of the pneumothorax.

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Strongyloides stercoralis (S. stercoralis) is an intestinal nematode endemic to tropical regions. An accelerated infection, known as a hyperinfection, occurs in immunocompromised patients, most commonly those treated chronically with glucocorticoids or those who have human T cell leukemia virus-1 (HTLV-1) infection. We describe a 67-year-old Hispanic female who presented with complaints of decreased oral intake and fatigue since three months. Hyponatremia on initial presentation was attributed to syndrome of inappropriate antidiuretic hormone (SIADH) secretion and managed with fluid restriction. Computed tomography (CT) of the chest revealed multiple pulmonary nodules suggestive of miliary tuberculosis, however, sputum acid-fast bacilli (AFB) smears were negative. Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) was performed and specimens sent for AFB testing. A concurrent endoscopy with biopsy was done to evaluate dysphagia. Both respiratory and gastrointestinal (GI) specimens were positive for Strongyloides stercoralis. Treatment with ivermectin and prophylactic antibiotics was started. The patient developed septic shock and had multiple episodes of gastrointestinal bleeding. Despite aggressive management, she expired. Subsequently, cultures for Mycobacterium tuberculosis (MTB) were positive and the autopsy demonstrated evidence of MTB infection in the lungs, liver, and lymph nodes. This case illustrates the importance of considering co-infection with Strongyloides stercoralis in patients with MTB, both associated with depressed cellular immunity.

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