Strongyloides hyperinfection in an HIV-positive kidney transplant recipient: a case report

Abstract

Background: Strongyloidiasis is caused by the helminth Strongyloides stercoralis and is well-recognised amongst transplant recipients. Serious complications, including Strongyloides hyperinfection which is a syndrome of accelerated autoinfection, or disseminated disease, can occur post-transplantation, resulting in significant morbidity and mortality. Here we present the first published case we are aware of, describing post-transplant Strongyloides hyperinfection in an HIV-positive kidney transplant patient. We discuss the diagnostic challenges and the role of pre-transplant screening. Case presentation: A 58-year-old African-American male, originally from the Caribbean, received a deceased donor kidney transplant for presumed focal segmental glomerulosclerosis. He was known to be HIV-positive, with a stable CD4 count, and an undetectable viral load. Five months post-transplant, he developed gastrointestinal symptoms and weight loss. He had a normal eosinophil count (0.1-0.2 × 109/L), negative serum cytomegalovirus DNA, and negative blood and stool cultures. His Strongyloides serology remained negative throughout. A diagnosis of Strongyloides hyperinfection was made by the histological examination of his duodenum and lung, which identified the parasites. He completed his course of treatment with Ivermectin but exhibited profound deconditioning and required a period of total parenteral nutrition. He was subsequently discharged after a prolonged hospital admission of 54 days. Conclusions: This case highlights the challenges in diagnosing Strongyloides infection and the need to maintain a high index of clinical suspicion. Non-invasive techniques for the diagnosis of Strongyloides may be insufficient. Routine pre-transplant serological strongyloidiasis screening is now performed at our centre.

A comprehensive review of Strongyloides stercoralis infection after solid organ and hematopoietic stem cell transplantation

“…A total of 72 studies 3,8–78 reported 91 SOT recipients, with 92 allografts and 93 episodes of S. stercoralis infection after SOT. There were 15 reports of S. stercoralis among HCT 45,79–92 .…”

“…The majority of strongyloidiasis cases (70/93, [75.3%]) were reported among kidney transplant (KT) recipients (68/91[74.7%]), 9,10,12,13,15,17,18,[21][22][23][25][26][27][28][29][30][35][36][37][38][39][40][41][42][43][45][46][47]49,[51][52][53][54]56,57,[59][60][61][62][63][64][66][67][68][69][70][72][73][74][75][76][77]…”

Strongyloides stercoralis hyperinfection syndrome mimicking pseudomembranous enteritis, complicated by Escherichia coli bacteremia and Pneumocystis jirovecii pneumonia in a patient after immunosuppressive therapy: a case report

“…Eosinophils are common markers of parasitic infections. However, eosinophil elevation is more pronounced in the early stages of the disease and less reliable in immunocompromised hosts [ 14 ]. There are data indicating that eosinophilia can be present in 70% of Strongyloides infections but only in 20% of patients with SHS [ 8 ].…”

“…There are data indicating that eosinophilia can be present in 70% of Strongyloides infections but only in 20% of patients with SHS [ 8 ]. Enzyme Linked Immuno Sorbent Assay (ELISA) has been reported to have 84–95% sensitivity and 82–100% specificity, but is often a false negative result in immunosuppressed individuals [ 14 ]. PCR is recommended to be more suitable for confirming the diagnosis than screening [ 15 ].…”

Human immunodeficiency virus and solid organ transplantation: a 15‐year retrospective audit at a tertiary Australian transplant centre

“…10 Australian guidelines no longer consider HIV infection a contraindication to SOT, 11 though experience here appears limited to case reports. 12,13 The Transplant Society of Australia and New Zealand suggests PLWH have an undetectable viral load, 'well maintained' CD4 count, stable antiviral regimen and no history of active opportunistic infections when considered for SOT. 11 PLWH who meet standard and HIV-specific criteria for SOT, outlined by others, 11,14,15 should be considered for transplantation.…”